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Hendee SJ, Fakhoury K, Karam SD. A Comprehensive Perspective on Educational and Economic Barriers for Utilization of Palliative Radiation Therapy in Hospice: A Narrative Review. Adv Radiat Oncol 2024; 9:101575. [PMID: 39309705 PMCID: PMC11415961 DOI: 10.1016/j.adro.2024.101575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 07/12/2024] [Indexed: 09/25/2024] Open
Abstract
Purpose Despite the agreed-on efficacy and benefits of palliative radiation therapy (PRT) to alleviate end-of-life complications related to cancer progression, PRT remains an underused treatment in the hospice-care setting.3-4,6-7 Common barriers for hospice patient use of PRT include educational and economic limitations. This paper discussed these barriers and ways to eliminate them based on previously published interventions. Methods and Materials Literature search on PubMed; 30 articles were selected by the authors. All articles included are published after the year 2000 in peer reviewed journals. Results Educational barriers for medical practitioners outside radiation oncology can be addressed by creating formal education programs that reduce knowledge gaps previously identified by survey-based research studies. For radiation oncologists, continued education should focus on increasing competence and comfort with end-of-life conversations and indications for use of single-fraction radiation for patients with advanced cancer. More information on radiation oncology options should be provided to patients. As for economic barriers, rapid-access programs that use advanced level practitioners can increase PRT access by the hospice population. Also, these programs can increase use of single-fraction radiation therapy (SFX RT) in patients with a shorter projected prognosis. SFX RT is beneficial in this setting because it decreases hospice expense and is as efficacious at palliating pain in patients with advanced cancer as multiple-fraction radiation. Conclusions The barriers of education and economic limitations can be addressed by: expanding the PRT curriculum for all practicing physicians, improving radiation oncologist palliative care knowledge, increasing PRT resources for patients, increasing number of rapid-access radiation therapy programs, and, when indicated, encouraging use of single-fraction radiation treatment for hospice patients.
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Affiliation(s)
| | | | - Sana D. Karam
- University of Colorado School of Medicine, Department of Radiation Oncology, Aurora, Colorado
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2
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Comprehensive assessment during palliative radiotherapy consultation optimizes supportive care for patients with advanced breast cancer. Support Care Cancer 2022; 30:8339-8347. [DOI: 10.1007/s00520-022-07246-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
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3
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Dennis K, Linden K, Zohr R, McGrath C, MacPherson M, Renaud J, Granville D, Gaudet M, Ali E. A Pre-implementation Study of Volumetric Modulated Arc Therapy for Same-day Planning and Treatment of Vertebral Bone Metastases Within a Rapid-access Palliative Radiotherapy Programme. Clin Oncol (R Coll Radiol) 2021; 33:661-666. [PMID: 33980462 DOI: 10.1016/j.clon.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/09/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
AIMS We aimed to develop a process for same-day contouring, planning, quality assurance and delivery of volumetric modulated arc therapy (VMAT) for vertebral bone metastases within our institution's rapid-access palliative radiotherapy programme. MATERIALS AND METHODS Two thoracic (T6-7, T3-7) and two lumbar (L2-3, L1-5) targets were contoured on computed tomography images acquired from an anthropomorphic phantom and five patient scans. Inverse planning aimed to provide coverage of a prescribed dose of 8 Gy with a combined lung V2Gy < 25% and a combined kidney mean dose <2 Gy. Serial plans were created to identify an efficient combination of six main planning variables specific to our treatment planning system: (i) voxel size (3 mm versus 5 mm), (ii) Monte Carlo statistical uncertainty (1% per calculation versus 3% per control point), (iii) fluence smoothing (medium versus high), (iv) number of iterations of segment shape changes during optimisation (1 versus 5), (v) dose calculation algorithm (Monte Carlo versus pencil beam) and (vi) number of arcs (single versus multiple). Contouring, planning, quality assurance and treatment delivery were timed. RESULTS The combination of planning variables deemed efficient and appropriate was: a 3 mm voxel size, statistical uncertainty of 1% per calculation, medium fluence smoothing, five iterations of segment shape changes, Monte Carlo dose calculation and single full arc delivery. Patient scan contouring times ranged from 7 to 9 min (T6-7), 11-13 min (T3-7), 5-7 min (L2-3) and 8-10 min (L1-5) and planning times ranged from 9 to 15 min (T6-7), 13-25 min (T3-7), 18-25 min (L2-3) and 21-31 min (L1-5). Physics quality assurance times ranged from 15 to 21 min and beam-on times ranged from 3 to 6 min. CONCLUSIONS The combined elements of VMAT for thoracic and lumbar vertebral bone metastases were completed in under 2 h. This new process makes same-day contouring, planning, quality assurance and treatment delivery of VMAT feasible within our rapid-access palliative radiotherapy programme.
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Affiliation(s)
- K Dennis
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada; Division of Radiation Oncology, University of Ottawa, Ottawa, Ontario, Canada.
| | - K Linden
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - R Zohr
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - C McGrath
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - M MacPherson
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada; Division of Radiation Oncology, University of Ottawa, Ottawa, Ontario, Canada
| | - J Renaud
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - D Granville
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - M Gaudet
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada; Division of Radiation Oncology, University of Ottawa, Ottawa, Ontario, Canada
| | - E Ali
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada; Division of Radiation Oncology, University of Ottawa, Ottawa, Ontario, Canada
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Wu SY, Yee E, Chan JW, Chapman CH, Boreta L, Braunstein SE. Timing of Urgent Inpatient Palliative Radiation Therapy. Adv Radiat Oncol 2021; 6:100670. [PMID: 33817413 PMCID: PMC8005735 DOI: 10.1016/j.adro.2021.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/19/2021] [Accepted: 02/03/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Urgent indications for palliative radiation therapy (RT) include malignant spinal cord compression, symptomatic brain metastases, pain, airway obstruction, and bleeding. Data on the timing of palliative RT in the inpatient setting are limited. We report our experience with inpatient palliative RT at a tertiary academic center and evaluate the effect of a dedicated inpatient palliative RT nurse practitioner (NP) on treatment timelines. Methods and Materials We performed a retrospective, single-institution review of 219 inpatients consulted for RT to sites of metastatic disease between May 2012 and May 2018. We compared time-to-treatment intervals before and after integrating an NP for palliative RT in August 2017. Results The median age of the 219 patients receiving RT was 61 years (interquartile range [IQR], 51-69 years). The most frequent indications were symptomatic brain metastases (73 patients [33%]), pain (61 patients [28%]), and cord/cauda compression (48 patients [22%]). The median time from consultation request to consult was 1 day (IQR, 0-2 days), and the median time from consultation request to first RT fraction was 3 days (IQR, 2-6 days). The median time from consultation request to RT was shorter for cord compression (2 [IQR, 1-4] days) than for pain (5 [IQR, 2-7] days) (P = .001) or symptomatic brain metastases (3 [IQR, 1-6] days; P = .037). With an NP, patients were more likely to undergo same-day consultation and simulation (75% vs 60%; P = .045), which was associated with shorter median duration from consultation to initiation of RT (1 [IQR, 0-3] days vs 4 [IQR, 2-7] days; P <.001). After the integration of an NP for palliative RT, patients had a higher median Karnofsky Performance Score (70 [IQR, 60-80] vs 50 [IQR, 40-60]; P < .001) and were more likely to complete their prescribed RT course (93% vs 82%; P = .05) Conclusions Time from consultation request to RT is necessarily short for urgent inpatient palliative RT. Advanced practice providers may facilitate and potentially expedite treatment, with significantly shorter times to treatment among patients who undergo same-day consultation and simulation.
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Affiliation(s)
- Susan Y Wu
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emily Yee
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Jason W Chan
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Christopher H Chapman
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Lauren Boreta
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco, California
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Dennis K, Harris G, Kamel R, Barnes T, Balboni T, Fenton P, Rembielak A. Rapid Access Palliative Radiotherapy Programmes. Clin Oncol (R Coll Radiol) 2020; 32:704-712. [DOI: 10.1016/j.clon.2020.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
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Martin EJ, Jones JA. Characterizing Palliative Radiotherapy Education in Hospice and Palliative Medicine Fellowship: A Survey of Fellowship Program Directors. J Palliat Med 2019; 23:275-279. [PMID: 31373879 DOI: 10.1089/jpm.2019.0119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Emily J Martin
- Department of Medicine, University of California, Los Angeles (UCLA), Los Angeles, California
| | - Joshua A Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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8
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Dennis K, Linden K, Balboni T, Chow E. Rapid access palliative radiation therapy programs: an efficient model of care. Future Oncol 2015; 11:2417-26. [DOI: 10.2217/fon.15.153] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Kristopher Dennis
- Division of Radiation Oncology, University of Ottawa; Radiation Medicine Program & Ottawa Hospital Research Institute, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H8L6, Canada
| | - Kelly Linden
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tracy Balboni
- Departments of Radiation Oncology & Psychosocial Oncology & Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, MA, USA
| | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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Abstract
This article updates the 2002 Jamie von Roenn article about "the palliation of commonly observed symptoms in older patients, including pain, neuropsychiatric, gastrointestinal, and respiratory symptoms." When palliative care was last covered in Clinics in Geriatric Medicine, President George W. Bush had just signed the No Child Left Behind Act, Homeland Security was being established, Michael Jackson won the Artist of the Century Award at the American Music Awards, and gas cost $1.61 a gallon. What has changed in the last decade and a half?
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Affiliation(s)
- Thomas J Smith
- Palliative Medicine, Johns Hopkins Medical Institutions, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Blalock 369, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Alcorn SR, DeWeese TL, Ellsworth S, Smith TJ. In Reply to Raince and Bloom and Olson. Int J Radiat Oncol Biol Phys 2015; 91:452-3. [DOI: 10.1016/j.ijrobp.2014.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 10/27/2014] [Accepted: 10/27/2014] [Indexed: 11/26/2022]
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Meyers DS. Palliative Radiation Therapy for the Hospice Patient: Nuances of Care and Reimbursement. J Oncol Pract 2015; 11:e87-8. [PMID: 27608495 DOI: 10.1200/jop.2014.002527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The author applauds the creation of a palliative radiation program for hospice patients in their community, and says physicians can do a better job of guiding patients to hospice earlier.
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