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

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.

Discontinuation of Palliative Brain Radiotherapy in Patients with Brain Metastases: A Case-Control Study

Background: Discontinuation of radiotherapy is rarely discussed in the scientific literature. The goal of this study was, therefore, to estimate the frequency of and reasons for treatment discontinuations in patients receiving radiotherapy for brain metastases from solid tumors and to identify factors predicting said discontinuations. Methods: All patients treated for brain metastases from solid tumors between 2010 and 2020 at our institution were retrospectively reviewed. In addition to collecting relevant patient characteristics, the Recursive Partitioning Analysis (RPA) and disease-specific Graded Prognostic Assessment (GPA) groups for each patient were calculated to assess the performance of these scores in predicting treatment discontinuations. Results: Out of 468 patients who underwent cranial radiotherapy, 35 treatments (7.5%) were discontinued. The most frequent reason was clinical deterioration, which was documented in 26 (74.3%) of discontinued treatments. Patients whose radiotherapy was discontinued had, on average, more leptomeningeal disease (20.0% vs. 12.6%), worse ECOG performance status (mean ECOG performance status 1.86 vs. 1.39), and more uncontrolled extracranial metastases (85.3% vs. 70.8%). The frequencies of treatment discontinuation increased with worse prognosis and differed significantly across RPA groups (p = 0.037) but not across GPA groups (p = 0.612). Conclusions: Treatment discontinuation occurred in 7.5% of cases, mostly due to clinical deterioration. Poor performance status, as well as more advanced disease and, in turn, poor prognosis, were associated with higher discontinuation rates.

Palliative radiotherapy: survival prognostic factors - single-centre retrospective cohort study

OBJECTIVE

Patients with non-curative malignancy can receive palliative radiotherapy (PR) to alleviate symptoms. However, choosing the right patient to receive PR can be challenging, as some patients may not survive long enough to gain benefit. This study aims to identify prognostic factors for overall survival (OS) and 30-day mortality (30DM) following PR and to test these in a real-world cohort.

METHOD

A retrospectively collected data set of all adults completing PR between 1 August 2018 and 31 December 2018 at a single centre (n=214, Southend University Hospital NHS Foundation Trust, UK) was used to test prognostic factors. Factors such as demographics, tumour primary, treatment area, fractionation regime, performance status (PS), progressive disease (PD), opioid or steroid use and haemoglobin level, as well as overall survival, were collected. Cox regression was used to examine survival predictors, and logistic regression was used to determine the predictive strength of factors for 30DM.

RESULTS

Overall 30DM was 14%. There was significantly worse survival in patients with poor PS (HR 1.2406, 95% CI 0.94 to 1.64. p=0.01). Patients with PS 3 had a median OS of 75 days and were more likely to experience 30DM (OR 6.2, 95% CI 1.226 to 45.42, p=0.03). Patients with PD outside of the radiation field (46%, 30 out of 65 documented) had significantly worse OS (HR 5.24, 95% CI 2.19 to 12.5, p<0.001).

CONCLUSION

Poor PS and PD were prognostic of OS and 30DM. Future work should include validation with a prospectively collected cohort.

Impact of the COVID-19 Pandemic Surge on Radiation Treatment: Report From a Multicenter New York Area Institution

PURPOSE

During the COVID-19 surge months of March and April 2020, our New York multicenter health system experienced an influx of cases with COVID-19. We sought to study the impact of the surge period on patients with cancer prescribed radiation treatment (RT).

METHODS

We reviewed our secure departmental quality assurance database for all patients who underwent RT planning simulations from March 6, 2020, through April 30, 2020. A priority level between 1 and 3 was prospectively assigned to each case based on faculty consensus to determine which patients required immediate RT. In May 2020, each faculty physician again retrospectively reviewed their patients from the database and provided additional commentary on how the COVID-19 pandemic had affected each patient's care. All statistics are descriptive.

RESULTS

A total of 412 RT courses in 406 unique patients were simulated for linear accelerator-based external beam RT. The median age was 66 years. Treatment intent was curative in 70.6% and palliative in 29.4%. Of the 412 cases, 66.7% were priority 1, 25% priority 2, and 7.8% priority 3. Two hundred thirty-nine cases (58%) underwent standard-of-care diagnosis, workup, and treatment plan. Seventeen patients (4.1%) electively canceled their RT, and 17 others (4.1%) electively delayed RT start. Thirty-four (8.3%) were prescribed hypofractionation to shorten their RT course, and 22 (5.3%) had a change in modality. Incomplete or delayed workup was identified in 19 cases (4.6%).

CONCLUSION

The COVID-19 pandemic surge resulted in 42% of our patients having a non-standard-of-care pathway. This outcome demonstrates a significant impact of the COVID-19 crisis on routine cancer care.

[Ethical stakes in palliative care in radiation oncology]

In 2021, the Ethics Commission of the SFRO has chosen the issue of the practice of palliative care in radiotherapy oncology. Radiation oncology plays a central role in the care of patients with cancer in palliative phase. But behind the broad name of palliative radiotherapy, we actually find a large variety of situations involving diverse ethical issues. Radiation oncologists have the delicate task to take into account multiple factors throughout a complex decision-making process. While the question of the therapeutic indication and the technical choice allowing it to be implemented remains central, reflection cannot be limited to these decision-making and technical aspects alone. It is also a question of being able to create the conditions for a singularity focused care and to build an authentic care relationship, beyond technicity. It is through this daily ethical work, in close collaboration with patients, and under essential conditions of multidisciplinarity and multiprofessionalism, that our fundamental role as caregiver can be deployed.

Clinical effects of morning and afternoon radiotherapy on high-grade gliomas

Initial clinical reports comparing the delivery of radiotherapy (RT) at distinct times of the day suggest that this strategy might affect toxicity and oncologic outcomes of radiation for multiple human tissues, but the clinical effects on high-grade gliomas (HGG) are unknown. The present study addresses the hypothesis that radiotherapy treatment time of the day (RT-TTD) influences outcome and/or toxic events in HGG. Patients treated between 2009-2018 were reviewed (n = 109). Outcomes were local control (LC), distant CNS control (DCNSC), progression-free survival (PFS), and overall survival (OS). RT-TTD was classified as morning if ≥50% of fractions were delivered before 12:00 h (n = 70) or as afternoon (n = 39) if after 12:00 h. The average age was 62.6 years (range: 14.5-86.9) and 80% were glioblastoma. The median follow-up was 10.9 months (range: 0.4-57.2). The 1y/3y LC, DCNSC, and PFS were: 61.3%/28.1%, 86.8%/65.2%, and 39.7%/10.2%, respectively. Equivalent PFS was found between morning and afternoon groups (HR 1.27; p = .3). The median OS was 16.5 months. Patients treated in the afternoon had worse survival in the univariate analysis (HR 1.72; p = .05), not confirmed after multivariate analysis (HR 0.92, p = .76). Patients with worse baseline performance status and treatment interruptions showed worse PFS and OS. The proportion of patients that developed grade 3 acute toxicity, pseudo progression, and definitive treatment interruptions were 10.1%, 9.2%, and 7.3%, respectively, and were not affected by RT-TTD. In conclusion, for patients with HGG, there was no difference in PFS and OS between patients treated in the morning or afternoon. Of note, definitive treatment interruptions adversely affected outcomes and should be avoided, especially in patients with low performance status. Based on these clinical findings, high-grade glioma cells may not be the best initial model to be irradiated in order to study the effects of chronotherapy.

The Role of Nutritional Support for Cancer Patients in Palliative Care

The role of nutritional support for cancer patients in palliative care is still a controversial topic, in part because there is no consensus on the definition of a palliative care patient because of ambiguity in the common medical use of the adjective palliative. Nonetheless, guidelines recommend assessing nutritional deficiencies in all such patients because, regardless of whether they are still on anticancer treatments or not, malnutrition leads to low performance status, impaired quality of life (QoL), unplanned hospitalizations, and reduced survival. Because nutritional interventions tailored to individual needs may be beneficial, guidelines recommend that if oral food intake remains inadequate despite counseling and oral nutritional supplements, home enteral nutrition or, if this is not sufficient or feasible, home parenteral nutrition (supplemental or total) should be considered in suitable patients. The purpose of this narrative review is to identify in these cancer patients the area of overlapping between the two therapeutic approaches consisting of nutritional support and palliative care in light of the variables that determine its identification (guidelines, evidence, ethics, and law). However, nutritional support for cancer patients in palliative care may be more likely to contribute to improving their QoL when part of a comprehensive early palliative care approach.

Factors Associated with Refusal or Discontinuation of Treatment in Patients with Bladder Cancer: A Cohort Population-Based Study in Taiwan

Cancer treatment causes adverse effects that lead to refusal or discontinuation of treatment. The purposes of this study were to identify 1) the factors associated with and 2) the reasons for refusing and discontinuing treatment in patients with bladder cancer (BC). We conducted a retrospective cohort study in patients diagnosed with BC in Taiwan from 1 January 2014 to 30 June 2019 using a linked cancer registry database. Of the 1247 BC patients in the study cohort, 2.1% reported refusing treatment. Patients with less education and those diagnosed at cancer stage II-IV were more likely to refuse treatment. The major reason for refusing treatment was "patient or the family considered patient's poor physical condition (chronic disease or unstable systemic disease), difficulty in enduring any condition likely to cause physical discomfort from disease treatment". A total of 4.3% of BC patients reported discontinuing treatment. Patients not living in the northern region of Taiwan and those diagnosed at cancer stage II-IV were more likely to terminate treatment before completion. The major reason given for discontinuing treatment was inconvenient transportation. Sufficient social resources and supportive care can help BC patients cope with the physical and psychological burden of treatment.

The influence of breast cancer subtype on survival after palliative radiation for osseous metastases

Background

Among patients with osseous metastases, breast cancer (BC) patients typically have the best prognosis. In the palliative setting, BC is often considered a single disease, but based on receptor status there are four distinct subtypes: luminal A (LA), luminal B (LB), triple negative (TN), and HER2‐enriched (HER2). We hypothesize that survival and palliative outcomes following palliative RT for osseous metastases correlate with breast cancer subtype (BCS).

Methods

We identified 3,895 BC patients with known receptor status who received palliative RT for osseous metastases from 2004–2013 in the National Cancer Database. Kaplan–Meier method with log‐rank testing and univariate/multivariate Cox‐regression was used to identify survival factors. Incomplete radiation courses, 30‐day mortality rate, and percentage remaining life spent receiving RT (PRLSRT) were calculated.

Results

Subtypes were 54% LA, 33% LB, 8% TN, and 5% HER2 with median survival of 34.1, 28.2, 5.3, and 15.7 months, respectively (p < 0.001). Overall 82% of patients received ≥10 fractions. Although BCS had limited effect on radiation regimens, TN received nearly twice as many single or hypofractionated (≤5 fractions) treatments, but the overall rate of these fraction schemes was low at 3.7 and 13.7%, respectively. Compared to LA and LB, TN and HER2 patients had worse palliative outcomes; higher rates of incomplete courses at 18.8% and 18.3% versus 12.7%–14.4%; higher 30‐day mortality post‐radiotherapy at 21.5% and 16.0% versus 6.3%–7.9%, and higher median PRLSRT of 7.7% and 3.7% versus 2.2%–2.4% for LA and LB. On multivariate analysis, BCS was associated with overall survival with TN (HR 3.7), HER2 (HR 1.75), and LB (HR 1.28) fairing worse than LA (p < 0.001).

Conclusions

BCS correlated with survival and palliative outcome following radiation to osseous metastases. BCS should be considered by physicians when planning palliative RT to maximize quality‐of‐life, avoid unnecessary treatment, and ensure palliative benefits.

Guidelines to Reduce Hospitalization Rates for Patients Receiving Curative-Intent Radiation Therapy During the COVID-19 Pandemic: Report From a Multicenter New York Area Institution

As the coronavirus disease 2019 pandemic spreads around the globe, access to radiation therapy remains critical for patients with cancer. The priority for all radiation oncology departments is to protect the staff and to maintain operations in providing access to those patients requiring radiation therapy services. Patients with tumors of the aerodigestive tract and pelvis, among others, often experience toxicity during treatment, and there is a baseline risk that adverse effects may require hospital-based management. Routine care during weekly visits is important to guide patients through treatment and to mitigate against the need for hospitalization. Nevertheless, hospitalizations occur and there is a risk of nosocomial severe acute respiratory syndrome coronavirus-2 spread. During the coronavirus disease 2019 pandemic, typical resources used to help manage patients, such as dental services, interventional radiology, rehabilitation, and others are limited or not at all available. Recognizing the need to provide access to treatment and the anticipated toxicity of such treatment, we have developed and implemented guidelines for clinical care management with the hope of avoiding added risk to our patients. If successful, these concepts may be integrated into our care directives in nonpandemic times.

Impact of Performance Status and Comorbidity on Palliative Radiation Treatment Tolerance and End-Of-Life Decision-Making

Purpose

Previous studies have indicated a relationship between functional status and comorbidity on overall survival when treating patients with bone and brain metastases. However, the degree to which these findings have been integrated into modern-day practice remains unknown. This study examines the impact of performance measures, including Karnofsky Performance Status (KPS) and comorbidity, on palliative radiation therapy treatment tolerance and fractionation schedule. The relationship between a shorter fractionation schedule (SFx) and pending mortality is examined.

Methods and materials

This study included patients who were treated with palliative intent to the brain or bone between January 1, 2016 and June 30, 2016. Demographic and medical characteristics collected included KPS score (stratified as good [90-100], fair [70-80], and poor (≤60]), socioeconomic status, comorbidity (binary measure using the Adult Comorbidity Evaluation-27 scale), site of metastatic disease, and treatment facility. Univariable analyses were performed using the Cox proportional hazards regression model to assess the impact of the variables on the prescribed number of fractions (binary measure, ≥10 [long fractionation schedule], and <10 [SFx]), and major treatment interruptions (MTIs; defined as missing ≥3 radiation therapy treatment days or ending treatment prematurely).

Results

A total of 145 patients were eligible for study inclusion, including 95 patients who were treated for bony metastatic disease and 50 patients for brain metastases. High comorbidity (P = .029) and both fair (P = .051) and poor (P = .065) functional status were associated with more frequent MTIs. However, high comorbidity and low KPS score were not associated with shorter treatment plans. In addition, patients with an earlier time to death were not more likely to receive an SFx (P = .871).

Conclusions

Low KPS and elevated comorbidity scores predict for a poorer prognosis and more frequent MTIs; however, there was no indication that physicians incorporated this information in the fractionation scheduling.