Survey on use of palliative radiotherapy in hospice care

Improving the Integration between Palliative Radiotherapy and Supportive Care: A Narrative Review

Palliative radiotherapy (PRT) is known to be effective in relieving cancer related symptoms. However, many studies and clinical practice show several barriers hindering its use and worsening the quality of patient support during PRT. Various solutions were proposed to overcome these barriers: training on PRT for supportive and palliative care specialists and training on palliative care for radiation oncologists, and introduction of pathways and organizational models specifically dedicated to PRT. Evidence on innovative organizational models and mutual training experiences is few and sparse. Therefore, the aim of this literature review is to present a quick summary of the information available on improving the PRT quality through training, new pathways, and innovative organizational models. The majority of studies on the integration of PRT with other palliative and supportive therapies present low levels of evidence being mostly retrospective analyses. However, it should be emphasized that all reports uniformly showed advantages coming from the integration of PRT with supportive therapies. To actively participate in the integration of PRT and palliative care, providing comprehensive support to the needs of patients with advanced cancer, radiation oncologists should not only plan PRT but also: (i) assess and manage symptoms and stress, (ii) rapidly refer patients to specialists in management of more complex symptoms, and (iii) participate in multidisciplinary palliative care teams. To this end, improved education in palliative care both in residency schools and during professional life through continuous medical education is clearly needed. In particular, effective training is needed for radiotherapy residents to enable them to provide patients with comprehensive palliative care. Therefore, formal teaching of adequate duration, interactive teaching methods, attendance in palliative care services, and education in advanced palliative care should be planned in post-graduated schools of radiotherapy.

Dosimetry Comparison of Palliative Radiation Plans Generated From Available Diagnostic CT Images Versus Dedicated CT Simulation for Inpatients

Introduction The morbidity sequelae of advanced cancer are often irreversible. Early palliative radiation can prevent, delay, and even improve these consequences. Treatment may be delayed due to a packed computed tomography (CT) simulation schedule or other logistics, including the cost and burden of arranging ambulance transportation when radiation centers are off-site. Objectives The primary objective was to determine the feasibility of using a recent diagnostic CT scan in lieu of a dedicated simulation CT to generate an adequate plan without sacrificing dosimetric goals and subsequent efficacy or tolerability. Secondary objectives included how much the lesion has grown, and how much earlier treatment could start if planned on a diagnostic CT scan. Materials/Methods For each inpatient treated with palliative radiation, a prior recent diagnostic CT scan was imported into the RayStation (RaySearch Laboratories, Stockholm, Sweden) planning system. From these diagnostic scans, planning treatment volumes (PTV) and organs at risk (OAR) were contoured using the same technique as the patient's actual treatment. The primary outcome was to compare both the PTV coverage and OAR dose between the plan generated from the diagnostic CT compared to that from the simulation CT. Our secondary outcomes include the mean time between CT simulation and first treatment, change in tumor volume between diagnostic scan and CT simulation, and the hottest 1% of each plan (D1). Results Between May and August 2019, a total of 22 inpatients were treated palliatively. Of those 22 patients, 10 patients (ages 32-92 years, median 64.5 years, 50% spine) met study criteria and had a diagnostic CT scan that was obtained within 14 days of simulation CT that was also compatible with our planning software. In the plans that were delivered, a mean of 98.8% (range 94.4-100%) of PTV was covered by at least 95% prescription dose. In the diagnostic CT plans, a mean of 95.4% (range 84.5-100%) of PTV was covered by at least 95% prescription dose. The difference between plans trended towards significance (p=0.061). When looking at patients receiving treatment to the spine or having a diagnostic CT within four days of the simulation CT, there was no statistically significant difference between the two plans (p=0.032 and 0.030, respectively). The OARs received, on average, 1.4% less mean radiation dose in the hypothetical plans (p=0.911). All OAR constraints were met in both groups. The mean time between diagnostic CT and CT simulation was 5.9 days and between CT simulation and first treatment was 1.9 days (range 0-5 days). The mean change in tumor volume was 22.64% smaller in the diagnostic CT scan plan. The D1 was an average 1% hotter in the hypothetical plans (p=0.16). Conclusion In hospitalized patients with an indication for palliative radiation, treatment planning on a pre-existing recent diagnostic CT scan produces comparable dose distributions without increases in dose to OARs when compared to the use of CT simulation scans, particularly for the treatment of the spine or when a very recent diagnostic CT is available. Bypassing CT simulation in select cases allows for earlier delivery of radiation with less patient and logistical burden. In combination with daily image guidance, this may translate to more timely delivery of radiation, less cost and burden to critically ill patients, and improved palliative benefit.

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.

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.

Inconsistencies in assessment of pain endpoints in radiotherapy for painful tumors: Analysis of original articles in the Green and Red Journals

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The frequency of use of the ICT has risen in research for PBMs.

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The frequency of the ICT use has been considerably limited for PNTs.

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None of the journal articles had investigated non-index pain.

Background and purpose

Consistent assessment of the pain response is essential for adequately comparing treatment efficacy between studies. We studied the assessment of pain endpoints in radiotherapy for painful bone metastases (PBMs) and painful non-bone-metastasis tumors (PNTs).

Material and methods

We performed a literature search in the Green (Radiotherapy and Oncology) and Red (International Journal of Radiation Oncology * Biology * Physics) Journals for full-length original articles published between 2009 and 2018. We only included articles that assessed palliation of tumor-related pain after radiotherapy. The data obtained included the definitions of pain response and assessment of non-index pain (pain other than that related to the irradiated tumors).

Results

Among the 1812 articles identified using the journals’ search function, 60 were included in the analysis. Thirty percent of the PBM articles and approximately half of the PNT articles did not report on analgesic use. Among the prospective studies, 68% of the articles on PBMs and 10% of the articles on PNTs used the International Consensus Endpoint. The PBM articles published in 2014–2018 utilized the International Consensus Endpoint more frequently than those published in 2009–2013 (p = 0.049). No articles reported information on non-index pain.

Conclusions

After the initial publication of the International Consensus Endpoint, the frequency of its use appears to have risen in PBM research; however, its use in PNT studies has been considerably limited. The International Consensus Endpoint should be consistently utilized in future studies on radiotherapy for painful tumors. Since none of the journal articles had investigated non-index pain, this issue may also needs to be addressed.

Palliative Radiation Therapy for Oncologic Emergencies in the Setting of COVID-19: Approaches to Balancing Risks and Benefits

Palliation of metastatic disease compromises a significant portion of radiation treatments in the United States. These patients present a unique challenge in resource-limited settings, as expeditious treatment is often required to prevent serious morbidity. In order to reduce the risk of infection with severe acute respiratory syndrome coronavirus-2 and maximize the benefit to patients, we present evidence-based recommendations for radiation in patients with oncologic emergencies. Radiation oncologists with expertise in the treatment of metastatic disease at a high-volume comprehensive cancer center reviewed the available evidence and recommended best practices for the treatment of common oncologic emergencies, with attention to balancing the risk of infection with severe acute respiratory syndrome coronavirus-2 and the potential morbidity of delaying treatment. Many prospective trials and national guidelines support the use of abbreviated courses of radiotherapy for patients with oncologic emergencies. As such, in the setting of the current coronavirus disease 2019 pandemic, the use of hypofractionated radiation therapy for patients requiring palliation for oncologic emergencies achieves desirable functional outcomes without compromising care.

Palliative radiotherapy: what do nurses know?

BACKGROUND

palliative radiotherapy can improve quality of life for patients who are symptomatic of advanced cancers. However, this treatment modality is underused and is often mistimed, which negates its potential benefit.

AIM

the aim of this study was to assess nursing knowledge of palliative radiotherapy in the context of caring for patients with a cancer diagnosis.

METHODS

a quantitative method of research was employed using a questionnaire to assess palliative radiotherapy knowledge among a purposive sample of 162 oncology and palliative care nurses.

FINDINGS

the response rate was 48.14%. More than half of respondents reported their knowledge of radiotherapy as insufficient for their practice and almost all agreed they would benefit from more education.

CONCLUSION

nurses require more training to identify when palliative radiotherapy would be an effective symptom control option; specific areas of focus for developing future radiotherapy educational programmes are highlighted.

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 Radiotherapy Education for Hospice and Palliative Medicine Fellows: A National Needs Assessment

Background: Insufficient knowledge of palliative radiotherapy (PRT) among hospice and palliative medicine (HPM) physicians is thought to be a barrier to the provision of high-quality palliative care. Objective: To assess the need for PRT education in HPM fellowship. Design: A cross-sectional survey of HPM fellows was conducted in June 2018. Setting/Subjects: The survey was distributed to accredited HPM fellowship programs in the United States for distribution to enrolled fellows; 114 fellows responded to the survey. Results: Nearly all respondents agreed that the principles of PRT should be taught in HPM fellowship, yet 51% had received no PRT education and 35% had received only one or two hours. Only 25% of respondents rated their working knowledge of PRT as sufficient, 40% felt confident in identifying radiation oncology emergencies or managing radiotherapy side effects, and 52% felt confident in assessing which patients to refer for radiotherapy. More than 75% agreed that were they more knowledgeable about PRT, they would be more likely to consider referral to radiation oncology, to collaborate with radiation oncologists, and to advocate for a short course of treatment based on a patient's prognosis or goals or care. Fellows who received PRT education in fellowship had significantly greater knowledge of and more favorable attitudes toward the use of radiotherapy. This difference was the greatest among fellows who had received at least five hours of PRT education. Conclusion: There is a need for PRT education in HPM fellowship. Efforts to address this need may lead to more appropriate utilization of PRT for patients with advanced cancer.

Outcomes and Characteristics of Patients Treated with Emergent Palliative Radiation Therapy

PURPOSE

Emergent palliative radiation therapy (PRT) of symptomatic metastases can significantly increase the quality of life of patients with cancer. In some contexts, this treatment may be underused, but in others PRT may represent an excessively aggressive intervention. The characterization of the current use of emergent PRT is warranted for optimized value and patient-centered care.

METHODS AND MATERIALS

This study is a cross-sectional retrospective analysis of all emergent PRT courses at a single academic tertiary institution across 1 year.

RESULTS

A total of 214 patients received a total of 238 treatment courses. The most common indications were bone (39%) and brain (14%) metastases. Compared with outpatients, inpatients had lower mean survival rates (2 months vs 6 months; P < .001), higher rates of stopping treatment early (19.1% vs 9.0%; P = .034), and greater involvement of palliative care (44.8% vs 24.1%; P < .001), but the same mean planned fractions (9.10 vs 9.40 fractions; P = .669). In a multiple predictor survival analysis, palliative care involvement (P = .025), male sex (P = .001), ending treatment early (P = .011), and having 1 of 3 serious indications (airway compromise, leptomeningeal disease, and superior/inferior vena cava involvement; P = .007) were significantly associated with worse overall survival.

CONCLUSIONS

Survival is particularly poor in patients who receive emergent PRT, and patient characteristics such as functional status and indication should be considered when determining fractionation schedule and dosing. A multi-institutional study of practice patterns and outcomes is warranted.

A Palliative Radiation Oncology Consult Service Reduces Total Costs During Hospitalization

CONTEXT

Palliative radiation therapy (PRT) is a highly effective treatment in alleviating symptoms from bone metastases; however, currently used standard fractionation schedules can lead to costly care, especially when patients are treated in an inpatient setting. The Palliative Radiation Oncology Consult (PROC) service was developed in 2013 to improve appropriateness, timeliness, and care value from PRT.

OBJECTIVES

Our primary objective was to compare total costs among two cohorts of inpatients with bone metastases treated with PRT before, or after, PROC establishment. Secondarily, we evaluated drivers of cost savings including hospital length of stay, utilization of specialty-care palliative services, and PRT schedules.

METHODS

Patients were included in our observational cohort study if they received PRT for bone metastases at a single tertiary care hospital from 2010 to 2016. We compared total costs and length of stay using propensity score-adjusted analyses. Palliative care utilization and PRT schedules were compared by χ² and Mann-Whitney U tests.

RESULTS

We identified 181 inpatients, 76 treated before and 105 treated after PROC. Median total hospitalization cost was $76,792 (range $6380-$346,296) for patients treated before PROC and $50,582 (range $7585-$620,943) for patients treated after PROC. This amounted to an average savings of $20,719 in total hospitalization costs (95% CI [$3687, $37,750]). In addition, PROC was associated with shorter PRT schedules, increased palliative care utilization, and an 8.5 days reduction in hospital stay (95% CI [3.2,14]).

CONCLUSION

The PROC service, a radiation oncology model integrating palliative care practice, was associated with cost-savings, shorter treatment courses and hospitalizations, and increased palliative care.

Predictors of Pain Palliation After Radiation Therapy for Painful Tumors: A Prospective Observational Study

PURPOSE

Although radiation therapy (RT) is an important part of treatment for cancer pain, prediction of the patient's pain response remains difficult. We evaluated the characteristics of patients, their tumors, and their pain to identify the predictors of pain palliation after RT for painful tumors.

METHODS

Our 3-center prospective observational study included patients scheduled for palliative or curative RT for painful tumors. Brief Pain Inventory data were collected at the start of RT and 1, 2, and 3 months thereafter. The pain response was assessed using the International Consensus Endpoint. The Mann-Whitney U-test was used to compare responders and nonresponders based on changes in the BPI scores. Predictors of the pain response were evaluated using the Fine-Gray model, in which death without a pain response was recorded as a competing risk. The independent variables were 11 a priori selected potential predictors with clinical relevance.

RESULTS

Of 302 analyzable patients, 262 (87%) had solid and 40 (13%) had hematologic tumors. The median total radiation dose was 30 Gy (range, 6-70.4 Gy). The pain response rate was 52% for 264 (87%) evaluable patients at 1-, 57% for 228 (75%) such patients at 2-, and 58% for 182 (60%) evaluable patients at 3-month follow-up. At 2-month follow-up, responders experienced a greater decrease in all 7 pain interference subscales of the Brief Pain Inventory compared to nonresponders. Multivariable analysis demonstrated that hematologic tumors (hazard ratio [HR], 1.85; 95% confidence interval [CI], 1.15-2.98), a neuropathic component of the index pain (HR, 1.50; 95% CI, 1.05-2.14), and opioid analgesic use before RT (HR, 0.65; 95% CI, 0.47-0.91) were independent significant predictors of pain response.

CONCLUSIONS

Patients with hematologic tumors, a neuropathic component of the index pain, and no treatment with opioid analgesics before RT were more likely to experience pain palliation after RT.

The rise of reimbursement-based medicine: the case of bone metastasis radiation treatment

It has been hypothesised that the reimbursement system pertaining to radiotherapy is influencing prescription practices for patients with cancer with bone metastases. In this paper, we present and discuss the results of an empirical study that was undertaken on patient records, referred to radiotherapy for the treatment of bone metastases, in a medium-size city, in southern Brazil, during the period of March 2006 to March 2014. Our findings seem to confirm this hypothesis: after a change in the reimbursement method, radiation prescriptions were adapted accordingly, in order to maximise profits. Once such patients become highly vulnerable due to their diagnoses, they also become susceptible to a subtle form of exploitation; physicians let patients believe that more radiation will be better for their health, and they do so despite knowing otherwise, and as it seems, out of pecuniary interests.

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.

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.

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.

Rapid access palliative radiation therapy programs: an efficient model of care

Palliating symptoms of advanced and metastatic cancers are one of the most common indications for radiation therapy (RT), and the demand for palliative RT is increasing. Dedicated rapid access palliative RT programs improve access to care, and can deliver RT in a more efficient and evidence-based manner than standard RT programs. In this narrative review, we discuss the role of palliative RT in comprehensive cancer care, and challenges that have faced patients trying to access it. We describe how rapid access programs developed to address these challenges and provide an overview of dedicated programs worldwide. Finally, we show how these programs can serve as models for multidisciplinary care and education, and sources of exciting research opportunities in clinical care and advanced technologies.

Variation in Intensity and Costs of Care by Payer and Race for Patients Dying of Cancer in Texas: An Analysis of Registry-linked Medicaid, Medicare, and Dually Eligible Claims Data

PURPOSE

To investigate end-of-life care for Medicaid, Medicare, and dually eligible beneficiaries dying of cancer in Texas.

METHODS

We analyzed the Texas Cancer Registry (TCR)-Medicaid and TCR-Medicare linked databases' claims data for 69,572 patients dying of cancer in Texas from 2000 to 2008. We conducted regression models in adjusted analyses of cancer-directed and acute care and total costs of care (in 2014 dollars) in the last 30 days of life.

RESULTS

Medicaid patients were more likely to receive chemotherapy and radiation therapy. Medicaid patients were more likely to have >1 emergency room (ER) [odds ratio (OR)=5.27; 95% confidence interval (CI), 4.76-5.84], and were less likely to enroll in hospice (OR=0.59; 95% CI, 0.55-0.63) than Medicare patients. Dual eligibles were more likely to have >1 ER visit than Medicare-only beneficiaries (OR=1.19; 95% CI, 1.07-1.33). Black and Hispanic patients were more likely to experience >1 ER visit and >1 hospitalization than whites. Costs were higher for nonwhite Medicare, Medicaid, and dually eligible patients compared with white Medicare enrollees.

CONCLUSIONS

Variation in acute care utilization and costs by race and payer suggest efforts are needed to address palliative care coordination at the end of life for Medicaid and dually eligible beneficiaries and minority patients dying of cancer.

30 day mortality in adult palliative radiotherapy--A retrospective population based study of 14,972 treatment episodes

Background: 30-day mortality (30DM) has been suggested as a clinical indicator of the avoidance of harm in palliative radiotherapy within the NHS, but no large-scale population-based studies exist. This large retrospective cohort study aims to investigate the factors that influence 30DM following palliative radiotherapy and consider its value as a clinical indicator.

Methods: All radiotherapy episodes delivered in a large UK cancer centre between January 2004 and April 2011 were analysed. Patterns of palliative radiotherapy, 30DM and the variables affecting 30DM were assessed. The impact of these variables was assessed using logistic regression.

Results: 14,972 palliative episodes were analysed. 6334 (42.3%) treatments were delivered to bone metastases, 2356 (15 7%) to the chest for lung cancer and 915 (5.7%) to the brain. Median treatment time was 1 day (IQR 1–7). Overall 30DM was 12.3%. Factors having a significant impact upon 30DM were sex, primary diagnosis, treatment site and fractionation schedule (p < 0.01).

Conclusion: This is the first large-scale description of 30-day mortality for unselected adult palliative radiotherapy treatments. The observed differences in early mortality by fractionation support the use of this measure in assessing clinical decision making in palliative radiotherapy and require further study in other centres and health care systems.

Clinic Offering Affordable Radiation Therapy to Increase Access to Care for Patients Enrolled in Hospice

This program increased access to palliative radiation therapy (RT) for patients in hospice who would otherwise have not been referred, and identified the need for educational activities at hospice agencies where staff turnover may be high and understanding about palliative RT can be limited.

Availability of single-fraction palliative radiotherapy for cancer patients receiving end-of-life care within the Veterans Healthcare Administration

BACKGROUND

Surveys demonstrate < 20% of radiation oncologists in the United States offer single-fraction palliative radiotherapy (RT) even though it is an acceptable standard of care. A study was conducted to investigate whether this held true for those practicing within the Veterans Healthcare Administration (VHA).

METHODS

All radiation oncologists currently practicing at VHA medical centers were surveyed. Comparisons and associations of responses were evaluated by Fisher's exact test.

RESULTS

The response rate was 90%. Half were full-time employees of the VHA, and the majority (70%) had thoroughly read guidelines on palliative RT for bone metastases recently published by either the American College of Radiology (ACR, 2009, 2012) or the American Society of Radiation Oncology (ASTRO, 2011). Single-fraction palliative RT for bone metastases had been prescribed by 76% of respondents, and 93% had prescribed a short course of ≤ 6 fractions. Respondents were less likely to have prescribed a single fraction for patients who had survival estimates of either > 6 months or > 12 months (66% versus 37%, p < 0.0001).Those not offering single-fraction palliative RT (24%) were more likely to be > 10 years out of training (37% versus 10%, p = 0.01), and to have worked in a private practice setting at some point in their career (36% versus 12%, p = 0.03).

CONCLUSIONS

A majority of radiation oncologists within the VHA offer single-fraction therapy to their patients. These data ensure access to palliative RT is not limited within this health care system by a preference for prolonged treatment courses that may discourage patients and clinicians from seeking this care.

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.

Role of radiation therapy in palliative care of the patient with cancer

Radiotherapy is a successful, time-efficient, well-tolerated, and cost-effective intervention that is crucial for the appropriate delivery of palliative oncology care. The distinction between curative and palliative goals is blurred in many patients with cancer, requiring that treatments be chosen on the basis of factors related to the patient (ie, poor performance status, advanced age, significant weight loss, severe comorbid disease), the cancer (ie, metastatic disease, aggressive histology), or the treatment (ie, poor response to systemic therapy, previous radiotherapy). Goals may include symptom relief at the site of primary tumor or from metastatic lesions. Attention to a patient's discomfort and transportation limitations requires hypofractionated courses, when feasible. Innovative approaches include rapid response palliative care clinics as well as the formation of palliative radiotherapy specialty services in academic centers. Guidelines are providing better definitions of appropriate palliative radiotherapy interventions, and bone metastases fractionation has become the first radiotherapy quality measure accepted by the National Quality Forum. Further advances in the palliative radiation oncology subspecialty will require integration of education and training between the radiotherapy and palliative care specialties.

Referring advanced cancer patients for palliative treatment: a national structured vignette survey of Australian GPs

BACKGROUND

Although (general practitioners) GPs have a role in managing patients with advanced cancer, little is known about their referral decisions.

AIM

The aim of this study was to explore, using structured vignettes, how GPs might manage patients presenting with advanced cancer.

DESIGN

A self-administered survey consisting of structured vignettes was administered to GPs in Australia. Fifty-six vignettes describing patients who may benefit from palliative care and/or treatment were constructed encompassing seven advanced cancer diagnoses (cerebral metastasis, lung metastases, renal cancer, bone metastases, ulcerating skin metastases, spinal metastases and stridor) and three clinical variables (age, prognosis and mobility). Seven vignettes were presented to each respondent. Respondents were asked if they would refer the patient and the benefits of different treatment modalities. Participant responses were compared with responses provided by an expert panel. Logistic regression and parametric tests were used to estimate odds of referral.

SETTING/PARTICIPANTS

The respondents were GPs, currently registered and practicing in Australia. Participants were selected randomly from a national list of practitioners.

RESULTS

Four hundred and seven questionnaires were received. There was wide variation (31%-97%) in the proportion of respondents who agreed with the expert panel. The odds of referral for radiotherapy varied the most. Significant predictive variables included patient age, mobility and prognosis and respondent demographics.

CONCLUSION

GPs' referral decisions for patients with advanced cancer appear to deviate from expert opinion and can be predicted using respondent and patient characteristics. If these data were reflected in clinical practice some patients may not be offered helpful palliative treatment options.

Palliative radiotherapy in patients with a poor performance status: the palliative effect is correlated with prolongation of the survival time

Background

The purpose of this study was to analyze the efficacy and tolerability of palliative radiotherapy (RT) in patients with a poor performance status (PS) and to evaluate the relationship between the palliative effect and survival time.

Methods

One hundred and thirty-three patients with a poor PS (Eastern Cooperative Oncology Group 3 or 4) were treated with palliative RT using the three-dimensional conformal technique and retrospectively analyzed. Each patient's primary symptom treated with palliative RT as the major cause of the poor PS was evaluated using the second item of the Support Team Assessment Schedule (STAS) at the start and one week after the completion of palliative RT.

Results

One hundred and fourteen (86%) of the 133 patients completed the planned palliative radiation dose. Grade 3 acute toxicity was observed in two patients (2%) and Grade 2 acute toxicity was observed in 10 patients (9%). No Grade 2 or higher late toxicities were observed, except for Grade 3 radiation pneumonitis in one patient. Improvement in the STAS scores between pre- and post-palliative RT was recorded in 76 (61%) of the 125 patients with available scores of STAS. A significant improvement in the mean STAS score between pre- and post-palliative RT was recognized (p < 0.0001). Improvement in the STAS score was found to be the most statistically significant prognostic factor for overall survival after palliative RT in both the multivariate and univariate analyses. The median overall survival time in the patients with an improvement in the STAS score was 6.4 months, while that in the patients without improvement was 2.4 months (p < 0.0005).

Conclusions

Palliative RT in patients with a poor PS provides symptomatic benefits in more than half of patients without inducing severe toxicities. The palliative effect is strongly correlated with prolongation of the survival time and may contribute to improving the remaining survival time in patients with metastatic/advanced cancer with a poor PS.

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.

The role of radiation therapy in controlling painful bone metastases

The management of painful bone metastases requires multidisciplinary care, with external beam radiation therapy (EBRT) providing relief that is effective and time efficient. Patients with bone metastases may require interventions including surgical decompression, osteoclast inhibitors, radiopharmaceuticals, and kyphoplasty or vertebroplasty, though EBRT should be included in the care of most of these patients, as well. Recent treatment-guideline publications for bone metastases greatly define the appropriate use of EBRT for this patient group, and they create a means by which treatment approaches may serve as quality measures of radiotherapy departments.

Utilization of radiotherapy services by a palliative care unit: pattern and implication

BACKGROUND

The role of radiotherapy in palliation is well recognized. Analyzing referrals from an inpatient palliative care unit (PCU) to the radiation oncology (RO) service may help in planning palliative care (PC) services and educational programs.

OBJECTIVE

To determine the pattern and rate of referrals from a PCU to the RO service at a tertiary oncology facility in Saudi Arabia.

METHODS

Referrals from the PCU to the RO service were prospectively identified over the period beginning November 27, 2007 and ending March 9, 2011. The appropriateness of referrals was determined by 2 radiation oncologists.

RESULTS

Of the 635 cancer admissions to the PCU, 25 (3.9%) referrals to RO were made, and 32 sites were irradiated. All patients had a poor performance status (ECOG > or = 3). The most common areas irradiated were vertebrae (40.6%), pelvis (18.7%) and other bony structures (28.1%). Pain control was the most frequent reason for referral (87.5%). Only one referral was regarded by the RO service as inappropriate, indicating that 96% of the referrals were appropriate. The mean time lapse between referral and starting radiation was 4 +/- 3.6 days. A total of 75% of the patients died in the PCU within a median of 30 days post radiotherapy.

CONCLUSION

The small minority of patients in the PCU referred for radiotherapy were deemed appropriate referrals by the radiation oncologists despite their poor performance status and limited time remaining. When planning a PCU with similar admission criteria, the availability of a radiotherapy facility in close proximity may not be a priority.

A review of recently published radiotherapy treatment guidelines for bone metastases: Contrasts or convergence?

Bone metastases are a common manifestation of malignancy, and external beam radiotherapy (EBRT) effectively and safely palliates the pain caused by this clinical circumstance. The myriad of EBRT dosing schemes and complexities involved with coordinating radiotherapy with other interventions necessitated the need for bone metastases treatment guidelines. Here we compare and contrast the bone metastases radiotherapy treatment guidelines recently published by the American Society for Radiation Oncology (ASTRO) and the American College of Radiology (ACR). These evaluations acknowledge current controversies in treatment approaches, they evaluate the nuances of ASTRO and ACR task force decision-making regarding standard approaches to care, and they project the upcoming research results that may clarify approaches to palliative radiotherapy for bone metastases. The results of these two dedicated radiotherapy guidelines are compared to the brief mentions of radiotherapy for bone metastases in the National Comprehensive Cancer Network (NCCN) guidelines. Finally, the paper describes how treatment guidelines may influence patterns of care and reimbursement by their use as quality measures by groups such as the National Quality Forum (NQF).

Relationships between family physicians' referral for palliative radiotherapy, knowledge of indications for radiotherapy, and prior training: a survey of rural and urban family physicians

BACKGROUND

The primary objective of this research was to assess the relationship between FPs' knowledge of palliative radiotherapy (RT) and referral for palliative RT.

METHODS

1001 surveys were sent to FPs who work in urban, suburban, and rural practices. Respondents were tested on their knowledge of palliative radiotherapy effectiveness and asked to report their self-assessed knowledge.

RESULTS

The response rate was 33%. FPs mean score testing their knowledge of palliative radiotherapy effectiveness was 68% (SD = 26%). The majority of FPs correctly identified that painful bone metastases (91%), airway obstruction (77%), painful local disease (85%), brain metastases (76%) and spinal cord compression (79%) can be effectively treated with RT, though few were aware that hemoptysis (42%) and hematuria (31%) can be effectively treated. There was a linear relationship between increasing involvement in palliative care and both self-assessed (p < 0.001) and tested (p = 0.02) knowledge. FPs had higher mean knowledge scores if they received post-MD training in palliative care (12% higher; p < 0.001) or radiotherapy (15% higher; p = 0.002). There was a strong relationship between FPs referral for palliative radiotherapy and both self-assessed knowledge (p < 0.001) and tested knowledge (p = 0.01).

CONCLUSIONS

Self-assessed and tested knowledge of palliative RT is positively associated with referral for palliative RT. Since palliative RT is underutilized, further research is needed to assess whether family physician educational interventions improve palliative RT referrals. The current study suggests that studies could target family physicians already in practice, with educational interventions focusing on hemostatic and other less commonly known indications for palliative RT.

Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer

BACKGROUND

Receipt of chemotherapy at the end of life (EOL) is considered an indicator of poor quality of care for medical oncology. The objective of this study was to characterize the use of radiotherapy (RT) in patients with nonsmall cell lung cancer (NSCLC) during the same period.

METHODS

Treatment characteristics of patients with incurable NSCLC who received RT at the EOL, defined as within 14 days of death, were analyzed from the National Comprehensive Cancer Network NSCLC Outcomes Database.

RESULTS

Among 1098 patients who died, 10% had received EOL RT. Patients who did and did not receive EOL RT were similar in terms of sex, race, comorbid disease, and Eastern Cooperative Oncology Group performance status. On multivariable logistic regression analysis, independent predictors of receiving EOL RT included stage IV disease (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.09-3.83) or multiorgan involvement (OR, 1.75; 95% CI, 1.08-2.84) at diagnosis, age <65 years at diagnosis (OR, 1.85; 95% CI, 1.21-2.83), and treating institution (OR, 1.24-5.94; P = .02). Nearly 50% of EOL RT recipients did not complete it, most commonly because of death or patient preference.

CONCLUSIONS

In general, EOL RT was received infrequently, was delivered more commonly to younger patients with more advanced disease, and often was not completed as planned. There also was considerable variation in its use among National Comprehensive Cancer Network institutions. Next steps include expanding this research to other cancers and settings and investigating the clinical benefit of such treatment.