Increasing use of advanced radiation therapy technologies in the last 30 days of life among patients dying as a result of cancer in the United States

Treatment Terminations During Radiation Therapy: A 10-Year Experience

PURPOSE

Patients undergoing radiation therapy may terminate treatment for any number of reasons. The incidence of treatment termination (TT) during radiation therapy has not been studied. Herein, we present a cohort of TT at a large multicenter radiation oncology department over 10 years.

METHODS AND MATERIALS

TTs between January 2013 and January 2023 were prospectively analyzed as part of an ongoing departmental quality and safety program. TT was defined as any premature discontinuation of therapy after initiating radiation planning. The rate of TT was calculated as a percentage of all patients starting radiation planning. All cases were presented at monthly morbidity and mortality conferences with a root cause reviewed.

RESULTS

A total of 1448 TTs were identified out of 31,199 planned courses of care (4.6%). Six hundred eighty-six (47.4%) involved patients treated with curative intent, whereas 753 (52.0%) were treated with palliative intent, and 9 (0.6%) were treated for benign disease. The rate of TT decreased from 8.49% in 2013 to 3.02% in 2022, with rates decreasing yearly. The most common disease sites for TT were central nervous system (21.7%), head and neck (19.3%), thorax (17.5%), and bone (14.2%). The most common causes of TT were hospice and/or patient expiration (35.9%), patient choice unrelated to toxicity (35.2%), and clinician choice unrelated to toxicity (11.5%).

CONCLUSIONS

This 10-year prospective review of TTs identified a year-over-year decrease in TTs as a percentage of planned patients. This decrease may be associated with the addition of root cause reviews for TTs and discussions monthly at morbidity and mortality rounds, coupled with departmental upstream quality initiatives implemented over time. Understanding the reasons behind TTs may help decrease preventable TTs. Although some TTs may be unavoidable, open discourse and quality improvement changes effectively reduce TT incidents over time.

Radiotherapy and palliative care outpatient clinic: a new healthcare integrated model in Italy

BACKGROUND

On the basis of substantial evidence demonstrate that palliative care combined with standard care improves patient, caregiver, and society outcomes, we have developed a new healthcare model called radiotherapy and palliative care (RaP) outpatient clinic were a radiation oncologist and a palliative care physician make a joint evaluation of advanced cancer patients.

METHODS

We performed a monocentric observational cohort study on advanced cancer patients referred for evaluation at the RaP outpatient clinic. Measures of quality of care were carried out.

RESULTS

Between April 2016 and April 2018, 287 joint evaluations were performed and 260 patients were evaluated. The primary tumor was lung in 31.9% of cases. One hundred fifty (52.3%) evaluations resulted in an indication for palliative radiotherapy treatment. In 57.6% of cases was used a single dose fraction of radiotherapy (8 Gy). All the irradiated cohort completed the palliative radiotherapy treatment. An 8% of irradiated patients received the palliative radiotherapy treatment in the last 30 days of life. A total of 80% of RaP patients received palliative care assistance until the end of life.

CONCLUSION

At the first descriptive analysis, the radiotherapy and palliative care model seem to respond to the need of multidisciplinary approach in order to obtain an improvement on quality of care for advanced cancer patients.

Prognostication in palliative radiotherapy—ProPaRT: Accuracy of prognostic scores

Background

Prognostication can be used within a tailored decision-making process to achieve a more personalized approach to the care of patients with cancer. This prospective observational study evaluated the accuracy of the Palliative Prognostic score (PaP score) to predict survival in patients identified by oncologists as candidates for palliative radiotherapy (PRT). We also studied interrater variability for the clinical prediction of survival and PaP scores and assessed the accuracy of the Survival Prediction Score (SPS) and TEACHH score.

Materials and methods

Consecutive patients were enrolled at first access to our Radiotherapy and Palliative Care Outpatient Clinic. The discriminating ability of the prognostic models was assessed using Harrell’s C index, and the corresponding 95% confidence intervals (95% CI) were obtained by bootstrapping.

Results

In total, 255 patients with metastatic cancer were evaluated, and 123 (48.2%) were selected for PRT, all of whom completed treatment without interruption. Then, 10.6% of the irradiated patients who died underwent treatment within the last 30 days of life. The PaP score showed an accuracy of 74.8 (95% CI, 69.5–80.1) for radiation oncologist (RO) and 80.7 (95% CI, 75.9–85.5) for palliative care physician (PCP) in predicting 30-day survival. The accuracy of TEACHH was 76.1 (95% CI, 70.9–81.3) and 64.7 (95% CI, 58.8–70.6) for RO and PCP, respectively, and the accuracy of SPS was 70 (95% CI, 64.4–75.6) and 72.8 (95% CI, 67.3–78.3).

Conclusion

Accurate prognostication can identify candidates for low-fraction PRT during the last days of life who are more likely to complete the planned treatment without interruption.

All the scores showed good discriminating capacity; the PaP had the higher accuracy, especially when used in a multidisciplinary way.

Interrupted Time-Series Analysis of Stereotactic Radiosurgery for Brain Metastases Before and After the Affordable Care Act

The 2010 Patient Protection and Affordable Care Act was aimed at reducing healthcare costs, improving healthcare quality, and expanding health insurance coverage among uninsured individuals in the United States. We examined trends in the utilization of radiation therapies and stereotactic radiosurgery before and after its implementation among U.S. adults hospitalized with brain metastasis. Interrupted time-series analyses of data on 383,934 Nationwide Inpatient Sample hospitalizations (2005-2010 and 2011-2013) were performed, whereby yearly and quarterly cross-sectional data were evaluated and Affordable Care Act implementation was considered the main exposure variable, stratifying by patient and hospital characteristics. Overall, we observed a declining trend in radiation therapy over time, with an upward shift post-Affordable Care Act. A downward shift in radiation therapy post-Affordable Care Act was observed among Northeastern and rural hospitals, whereas an upward shift was noted among specific patient (females, 18-39 or ≥ 65 years of age, Charlson Comorbidity Index (CCI) ≥10, non-elective admissions, Medicare, self-pay, no pay or other insurance) and hospital (Midwestern, Western, non-teaching urban) subgroups. Stereotactic radiosurgery utilization among recipients of radiation therapy increased over time among Hispanics, elective admissions, and rural hospitals, whereas post-Affordable Care Act was associated with increased stereotactic radiosurgery among African-Americans and non-elective admissions and decreased stereotactic radiosurgery among elective admissions, and rural hospitals. Whereas hospitalized adults in the United States utilized less radiation therapy over the nine-year period, utilization of radiation therapy, in general, and stereotactic radiosurgery, in particular, were not consistent among distinct subgroups defined by patient and hospital characteristics, with some traditionally underserved populations more likely to receive healthcare services post-Affordable Care Act. The Affordable Care Act may be helpful at closing the gap in access to technological advances such as stereotactic radiosurgery for treating brain metastases.

Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care

BACKGROUND

Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals.

MATERIALS AND METHODS

All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed.

RESULTS

In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045).

CONCLUSIONS

Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.

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.

The challenge of sustainability in healthcare systems: cost of radiotherapy in the last month of life in an Italian cancer center

Purpose

Cost evaluation is becoming mandatory to support healthcare sustainability and optimize the decision-making process. This topic is a challenge, especially for complex and rapidly evolving treatment modalities such as radiotherapy (RT). The aim of the present study was to investigate the cost of RT in the last month of life of patients in an Italian cancer center.

Methods

This was a retrospective study on a cancer population (N= 160) who underwent RT or only an RT planning simulation in an end of life (EOL) setting. The cost of RT procedures performed on patients was collected according to treatment status, care setting, and RT technique used. Costs were valued according to the sum of reimbursements relating to all procedures performed and assessed from the perspective of the National Health System.

Results

The total cost of RT in the last month of life was €244,774, with an average cost per patient of €1530. Around 7.7% and 30.3% of the total cost was associated with patients who never started RT or who discontinued RT, respectively, while the remaining 62.0% referred to patients who completed treatment. Costs associated with outpatient and inpatient settings represented 54.3% and 38.6% of the total cost, respectively. The higher average cost per patient for the never-started and discontinued groups was correlated with patients who had a poor ECOG Performance Status.

Conclusion

Improved prognostic accuracy and a better integration between radiotherapy and palliative care units could be a key to a better use of resources and to a reduction in the cost of EOL RT.

Imaging response assessment following stereotactic body radiotherapy for solid tumour metastases of the spine: Current challenges and future directions

Patients with metastatic disease are routinely serially imaged to assess disease burden and response to systemic and local therapies, which places ever-expanding demands on our healthcare resources. Image interpretation following stereotactic body radiotherapy (SBRT) for spine metastases can be challenging; however, appropriate and accurate assessment is critical to ensure patients are managed correctly and resources are optimised. Here, we take a critical review of the merits and pitfalls of various imaging modalities, current response assessment guidelines, and explore novel imaging approaches and the potential for radiomics to add value in imaging assessment.

Palliative radiotherapy near the end of life

Background

A significant proportion of patients with advanced cancer undergo palliative radiotherapy (RT) within their last 30 days of life. This study characterizes palliative RT at our institution and aims to identify patients who may experience limited benefit from RT due to imminent mortality.

Methods

Five hundred and-eighteen patients treated with external beam RT to a site of metastatic disease between 2012 and 2016 were included. Mann-Whitney U and chi-squared tests were used to identify factors associated with RT within 30 days of death (D₃₀RT).

Results

Median age at RT was 63 years (IQR 54–71). Median time from RT to death was 74 days (IQR 33–174). One hundred and twenty-five patients (24%) died within 30 days of RT. D₃₀RT was associated with older age at RT (64 vs. 62 years, p = 0.04), shorter interval since diagnosis (14 vs. 31 months, p <  0.001), liver metastasis (p = 0.02), lower KPS (50 vs. 70, p <  0.001), lower BMI (22 vs. 24, p = 0.001), and inpatient status at consult (56% vs. 26%, p < 0.001). Patients who died within 30 days of RT were less likely to have hospice involved in their care (44% vs. 71%, p = 0.001). D₃₀RT was associated with higher Chow and TEACHH scores at consult (p < 0.001 for both).

Conclusions

Twenty-four percent of patients received palliative RT within 30 days of death. Additional tools are necessary to help physicians identify patients who would benefit from short treatment courses or alternative interventions to maximize quality at the end of life.

Impact of Accuracy of Survival Predictions on Quality of End-of-Life Care Among Patients With Metastatic Cancer Who Receive Radiation Therapy

PURPOSE:

For patients treated with palliative radiation, we examined the association between life expectancy predictions by radiation oncologists and aggressive end-of-life care.

MATERIALS AND METHODS:

We included decedents from a study that assessed the ability of oncologists to predict survival of patients with metastatic cancer who received radiation. We identified patients who died within 12 months of study enrollment to assess accuracy of predictions. Aggressive end-of-life care was defined by the National Quality Forum, ASCO Quality Oncology Practice Initiative metrics, and advanced radiation modalities in the last month of life. Survival predictions were categorized as follows: correct (< 12 months), 12 to 18 months, 18 to 24 months, and more than 24 months. We assessed association between prediction and aggressive end-of-life care using a generalized estimation equation.

RESULTS:

Of 489 decedents, we identified 467 encounters with survival estimates. Overall, 156 decedents (32%) met at least one metric of aggressive end-of-life care. Factors associated with aggressive end-of-life care included younger age, female sex, primary cancer diagnosis, no brain metastases, and private insurance. In each encounter when an oncologist predicted survival, 363 predictions (78%) were correct (< 12 months), 54 (11%) incorrectly predicted 12 to 18 months, 27 (6%) predicted 18 to 24 months, and 23 (5%) predicted more than 24 months. Compared with patients who had encounters that had correct survival predictions, patients predicted to live more than 24 months were more likely to meet at least one metric of aggressive end-of-life care (odds ratio, 2.55; 95% CI, 1.09 to 5.99; P = .03).

CONCLUSION:

Inaccurate survival predictions by oncologists are associated with more aggressive end-of-life care for patients with advanced cancer.

Preventing Discontinuation of Radiation Therapy: Predictive Factors to Improve Patient Selection for Palliative Treatment

PURPOSE

Approximately one third of patients with cancer require palliative radiation therapy (PRT), yet no guidelines exist for optimal patient selection. We have observed that many patients who begin PRT do not complete their prescribed treatment. Our study sought to identify factors associated with discontinuation of PRT, assess for a relationship with survival, and inform patient selection.

METHODS

We performed an institutional review board-approved retrospective analysis of patients with cancer treated in a multicenter radiation oncology department in 2014. Of 297 patients who began PRT, 60 discontinued and 237 completed treatment. Primary end points included discontinuation and overall survival.

RESULTS

Patient factors were analyzed for association with discontinuation of PRT and overall survival, respectively, using logistic regression and Cox proportional regression models. Factors associated with discontinuation were low Karnofsky performance status (KPS) score, high number of fractions prescribed, and treatment site other than bone metastasis. The odds of discontinuing PRT decreased by approximately 52% for every 10-point increase in KPS score (odds ratio, 0.48; 95% CI, 0.36 to 0.63; P < .001). Factors associated with shorter survival included discontinuation of PRT, low KPS score, community practice location, multiple comorbidities, and treatment of brain metastases. Patients who discontinued treatment were more likely to die than patients who completed treatment, independent of other factors (hazard ratio, 3.67; 95% CI, 2.41 to 5.61; P < .001).

CONCLUSION

Patients with low KPS scores, long treatment courses, and those treated to sites other than bone metastasis were significantly more likely to discontinue treatment. Discontinuation was predictive for poor survival. Pretreatment evaluation of KPS, comorbidities, and brain metastases can help guide appropriate patient selection for PRT.

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.