Standardizing Breast Adjuvant Radiation Therapy Practices in a Diverse Health System through Development of a Delphi Consensus Supported Clinical Algorithm

PURPOSE/OBJECTIVE(S)

Adjuvant radiation therapy (RT) for early breast cancer is a highly effective treatment option. However, the multitude of available techniques backed by strong clinical evidence can result in a lack of consistency in treatment approaches, even within a single healthcare organization. This presents challenges for both providers and patients in making informed decisions. To address this issue, our radiation department, which serves a large and diverse health system, developed a clinical algorithm for adjuvant RT for breast cancer. This algorithm was created to enhance the quality and standardization of care delivered across our network.

MATERIALS/METHODS

A modified Delphi technique was used. A panel of eight experienced breast radiation oncologists from our institution was assembled. The panel first identified the common clinical scenarios encountered in treating patients with adjuvant breast RT, and then made recommendations for the primary and alternative approaches for each scenario. NCCN guidelines, ASTRO executive summaries, and published national and international randomized trials were used for reference. In case of disagreements, the final recommendation was reached through a majority vote. The draft algorithm was also shared with medical oncologists, surgeons, and patient advocates to gather their input prior to final approval by the expert panel.

RESULTS

Consensus was reached for three broad clinical scenarios for patients who have undergone lumpectomy or mastectomy: Ductal Carcinoma in Situ (DCIS), Invasive Cancer Node Negative (ICN0), and Invasive Cancer Node Positive (ICN+). The panel agreed subdivision of the scenarios into three risk groups (low, intermediate, and high) and three age groups, based on guidelines and consensus statements. For DCIS patients, size, grade, margin status, hormone receptor status, and tumor focality were used for further stratification. For ICN0 patients, HER2 receptor status and lymphovascular space invasion were also included. For ICN+ patients, nodal status (negative versus 1-3 positive nodes versus more than 3 positive nodes) was used for stratification. Additionally, DCIS and ICN0 patients were further divided into age groups. The panel reached consensus recommendations for RT, including whole breast RT, partial breast RT, chest wall RT, regional nodal irradiation, or omission of RT for each sub-group. Clinical trial enrollment was also recommended where appropriate.

CONCLUSION

A breast cancer adjuvant RT algorithm was developed with the aim of standardizing care for patients with breast cancer. Implementation is expected to standardize treatment recommendations in our health system and to streamline the shared decision-making process with patients.

Treatment Terminations during Radiation Therapy: A Ten-Year Experience

PURPOSE/OBJECTIVE(S)

Disruptionsin cancer care adversely affect clinical outcomes, particularly when a patient does not complete the prescribed course of treatment. The impact of treatment termination (TT) during radiation therapy has not been well studied. This study addresses TT in a large multi-center department of radiation oncology over a 10-year time period.

MATERIALS/METHODS

TTs of patients undergoing radiation treatment between January 2013 and December 2022 were prospectively tracked as part of departmentalquality and safety monitoring. A TT was defined as the discontinuation of therapy at any point following consent and simulation. Causes of TTs were categorized as: hospice/death, physician choice related to toxicity, physician choice unrelated to toxicity, patient choice related to toxicity, patient choice unrelated to toxicity, progression of disease, non-cancer illness, or other. The rate of TT was calculated as a percentage of all new patients who start radiation treatments. As part of our ongoing department quality and safety program, incremental changes were made to pre-treatment evaluation and scheduling processes, collectively referred to as the "No-Fly" policy. TT rates during three iterations of this policy were compared.

RESULTS

Outof 28,707 planned treatment courses, a total of 1,467 TTs were identified (5.1%). 688 (46.9%) involved patients treated with curative intent, 770 (52.5%) with palliative intent, and 9 (0.6%) for benign disease. The rate of TT decreased from 9.3% in 2013 to 3.3% in 2022. Relative to evolutions of our No-Fly policy, the overall TT rate decreased from 8.8% under No-Fly 1 (2013-2014), to 5.2% during No-Fly 2 (2015-2018), and 4.0% with No-Fly 3 (2019-2022) (ANOVA, p<0.001). The most common sites for TT were H&N (19.3%), CNS (17.9%), and Bone Metastases (17.9%). The most common cause of TT was hospice and/or death (36.5%), 69.1% of which were in patients receiving palliative treatments. Other common causes included patient choice unrelated to toxicity (35%), physician choice unrelated to toxicity (8.8%), and progression of disease (7.6%). There were 473 TTs without radiation dose given (1.6% of planned treatments, 32.3% of TTs).

CONCLUSION

Radiation TTs reflect major deviations from the original care plan. This large cohort study highlights the value of open departmental discourse about TTs, which prompted quality improvement changes that reduced TTs over time. Future studies addressing clinical outcomes can direct treatment decision-making and improve care for our patients.

Psychological Treatment for Patients Receiving Radiation: Results of NRG Oncology/RTOG 0841

PURPOSE

NRG/RTOG 0841 assessed the feasibility of a depression screening procedure in patients receiving radiation therapy (RT). As a secondary endpoint, availability and barriers to psychosocial care data were collected in hopes of providing recommendations for improved psychosocial care among patients receiving RT.

METHODS AND MATERIALS

Patients starting RT were prospectively recruited and assessed with self-reported distress screening tools. Patients exceeding a validated cutoff and a sample of patients who screened negative received the Structured Clinical Interview for DSM-IV (SCID) mood disorder modules via telephone. During that SCID evaluation, patients completed a validated scale ranking interview on barriers to psychosocial care and interest in various psychosocial intervention modalities.

RESULTS

A total of 463 patients from 35 community-based and 2 academic RT oncology sites were recruited. Of the 455 eligible, 75 (16%) exceeded screening cutoffs for depressive symptoms. From this group, 78 patients completed the SCID; most were female (76%), white (88%), and had breast cancer (55%). Overall, the most common barriers to treatment, regardless of insurance, were costs (58%), daily responsibilities (44%), and physical health symptoms (38%). Patients from RT facilities without mental health services were significantly more likely to report difficulty with physical health problems, specifically serious illness and walking, compared with those treated at RT facilities with services (P = .013 and P = .039, respectively). Overall, there was interest in obtaining psychosocial services with face-to-face counseling at the cancer center and printed educational materials as the most commonly preferred interventions. Patients with difficult barriers to psychosocial interventions were significantly less interested in support away from the cancer center (P = .016), telephone and Internet counseling (P = .0062 &P = .011), and Internet support (P = .0048).

CONCLUSION

Radiation oncology patients are interested in obtaining psychosocial services but face barriers to access to mental health services including cost, debilitating symptoms, and time constraints that prevent adequate care.

Screening for depression in cancer patients receiving radiotherapy: Feasibility and identification of effective tools in the NRG Oncology RTOG 0841 trial

BACKGROUND

Brief tools are needed to screen oncology outpatients for depressive symptoms.

METHODS

Patients starting radiotherapy for the first diagnosis of any tumor completed distress screening tools, including the 9-item Patient Health Questionnaire (PHQ-9), the 2-item Patient Health Questionnaire (PHQ-2), the National Comprehensive Cancer Network Distress Thermometer (NCCN-DT), and the Hopkins Symptom Checklist (HSCL) (25-item version). Patients exceeding validated cutoff scores and a systematic sample of patients whose screening was negative completed the Structured Clinical Interview for DSM-IV (SCID) mood disorder modules via telephone.

RESULTS

Four hundred sixty-three patients from 35 community-based radiation oncology sites and 2 academic radiation oncology sites were recruited. Sixty-six percent of the 455 eligible patients (n = 299) were women, and the eligible patients had breast (45%), gastrointestinal (11%), lung (10%), gynecologic (6%), or other cancers (27%). Seventy-five (16.5%) exceeded screening cutoffs for depressive symptoms. Forty-two of these patients completed the SCID. Another 37 patients whose screening was negative completed the SCID. Among the 79 patients completing the SCID, 8 (10.1%) met the criteria for major depression, 2 (2.5%) met the criteria for dysthymia, and 6 (7.6%) met the criteria for an adjustment disorder. The PHQ-2 demonstrated good psychometric properties for screening for mood disorders with a cutoff score of ≥3 (receiver operating characteristic area under the curve [AUC], 0.83) and was comparable to the PHQ-9 ( > 9; AUC = 0.85). The NCCN-DT did not detect depression (AUC = 0.59).

CONCLUSIONS

The PHQ-2 demonstrated good psychometric properties for screening for mood disorders, which were equivalent to the PHQ-9 and superior to the NCCN-DT. These findings support using the PHQ-2 to identify patients in need of further assessment for depression, which has a low prevalence but is a clinically significant comorbidity. These findings could inform the implementation of distress screening accreditation standards. Cancer 2017;123:485-493. © 2016 American Cancer Society.