Palliative radiotherapy practice within Western European countries: impact of the radiotherapy financing system?

Costs analysis of radiotherapy for breast cancer in Indonesia: a comparison between reimbursement tariffs and actual costs

BACKGROUND

Breast cancer is the most common cancer in Indonesia, and radiotherapy plays an essential role in its treatment. However, since 2016, the INA-CBGs (Indonesian Case-Based Groups) tariffs for radiotherapy have remained unchanged. This study aimed to assess the disparity between tariffs and actual costs of outpatient radiotherapy in breast cancer, using real-world data from two Indonesian hospitals.

METHODS

We conducted a retrospective cohort study in a national public referral hospital and a private hospital. Breast cancer claims data were collected from 2017 to 2022 from the Department of Accounting/Finance with INA-CBGs tariff code of C-3-10-0 (radiotherapy procedures for outpatients). We estimated total actual costs, actual costs per patient and visit, and the cost-tariffs ratio. Differences between the actual costs and tariffs were analyzed using Mann-Whitney test.

RESULTS

A total of 3,890 breast cancer patients were included in the study, of which 74.4% were from the national public referral hospital. In the national public referral hospital and private hospital, the total actual costs of outpatient radiotherapy in breast cancer were USD 19,028,791.17 and USD 5,279,980.74, with median costs per patient of USD 6,560.00 [3,679.81;7,518.46] and USD 5,110.00 [839.15;7,552.34], and median costs per visit of USD 272.00 [253.16;274.47] and USD 272.00 [211.31;305.50], respectively. Over the study period, the cost-tariffs ratio was 86.85% and 59.07% in the national public referral hospital and private hospital, respectively. The differences between the tariffs and total actual costs were statistically significant in both hospitals and increased throughout the years.

CONCLUSIONS

For both hospitals, the INA-CBGs tariffs for outpatient radiotherapy services for breast cancer were insufficient to fully cover the actual costs during the review period. Furthermore, the difference between the tariffs and the actual costs increased over the years, emphasizing the need for revision of the C-3-10-0 tariffs. It is crucial to ensure coverage of all actual costs to ensure the sustainability, accessibility, and availability of radiotherapy treatment for breast cancer patients in Indonesia.

Quality of Decision Making in Radiation Oncology

High-quality decision making in radiation oncology requires the careful consideration of multiple factors. In addition to the evidence-based indications for curative or palliative radiotherapy, this article explores how, in routine clinical practice, we also need to account for many other factors when making high-quality decisions. Foremost are patient-related factors, including preference, and the complex interplay between age, frailty and comorbidities, especially with an ageing cancer population. Whilst clinical practice guidelines inform our decisions, we need to account for their applicability in different patient groups and different resource settings. With particular reference to curative-intent radiotherapy, we explore decisions regarding dose fractionation schedules, use of newer radiotherapy technologies and multimodality treatment considerations that contribute to personalised patient-centred care.

Sustainability in radiation oncology: opportunities for enhancing patient care and reducing CO2 emissions in breast cancer radiotherapy at selected German centers

BACKGROUND AND OBJECTIVE

Radiotherapy often entails a substantial travel burden for patients accessing radiation oncology centers. The total travel distance for such treatments is primarily influenced by two factors: fractionation schedules and the distances traveled. Specific data on these aspects are not well documented in Germany. This study aims to quantify the travel distances for routine breast cancer patients of five radiation oncology centers located in metropolitan, urban, and rural areas of Germany and to record the CO2 emissions resulting from travel.

METHODS

We analyzed the geographic data of breast cancer patients attending their radiotherapy treatments and calculated travelling distances using Google Maps. Carbon dioxide emissions were estimated assuming a standard 40-miles-per-gallon petrol car emitting 0.168 kg of CO2 per kilometer.

RESULT

Addresses of 4198 breast cancer patients treated between 2018 and 2022 were analyzed. Our sample traveled an average of 37.2 km (minimum average: 14.2 km, maximum average: 58.3 km) for each radiation fraction. This yielded an estimated total of 6.2 kg of CO2 emissions per visit, resulting in 156.2 kg of CO2 emissions when assuming 25 visits (planning, treatment, and follow-up).

CONCLUSION

Our study highlights the environmental consequences associated with patient commutes for external-beam radiotherapy, indicating that reducing the number of treatment fractions can notably decrease CO2 emissions. Despite certain assumptions such as the mode of transport and possible inaccuracies in patient addresses, optimizing fractionation schedules not only reduces travel requirements but also achieves greater CO2 reductions while keeping improved patient outcomes as the main focus.

Equity, Diversity, and Inclusion in Radiation Oncology: A Bibliometric Analysis and Critical Review

The promotion of equity, diversity, and inclusion (EDI) is being increasingly pursued in health care, both in general and within radiation oncology. Because bibliometrics is a powerful tool to reveal the scientific literature on a specific topic during a certain timespan, a systematic bibliometric analysis of the documents published on EDI in radiation oncology was performed, aiming at exploring common patterns in research and emerging trends, tracking collaborations and networks, and anticipating future directions in clinical research. Standard descriptive statistics and bibliometric techniques were used in the analysis. A collaboration network and thematic map were generated from the data. Four domains were represented: (1) motor themes, including themes well developed and important for the structuring of the research field; (2) niche themes, representing the isolated topics that do not share important external links with other themes; (3) emerging themes, referring to still weakly developed topics; and (4) basic themes, including the essential topics. EDI in the profession of radiation oncology is essential to ensure that the workforce delivering radiation oncology care both draws from the full talent pool of human capital and delivers the highest quality science and clinical care to all patients. The burgeoning literature on EDI in radiation oncology suggests that a large and growing cohort of scholars within radiation oncology are dedicated to addressing these important challenges.

Early economic modeling of magnetic resonance image-guided high intensity focused ultrasound compared to radiotherapy for pain palliation of bone metastases

Introduction

Magnetic Resonance Image-guided High Intensity Focused Ultrasound (MR-HIFU) is a non-invasive treatment option for palliative patients with painful bone metastases. Early evidence suggests that MR-HIFU is associated with similar overall treatment response, but more rapid pain palliation compared to external beam radiotherapy (EBRT). This modelling study aimed to assess the cost-effectiveness of MR-HIFU as an alternative treatment option for painful bone metastases from the perspective of the German Statutory Health Insurance (SHI).

Materials and methods

A microsimulation model with lifelong time horizon and one-month cycle length was developed. To calculate the incremental cost-effectiveness ratio (ICER), strategy A (MR-HIFU as first-line treatment or as retreatment option in case of persistent pain or only partial pain relief after EBRT) was compared to strategy B (EBRT alone) for patients with bone metastases due to breast, prostate, or lung cancer. Input parameters used for the model were extracted from the literature. Results were expressed as EUR per quality-adjusted life years (QALYs) and EUR per pain response (i.e., months spent with complete or partial pain response). Deterministic and probabilistic sensitivity analyses (PSA) were performed to test the robustness of results, and a value of information analysis was conducted.

Results

Compared to strategy B, strategy A resulted in additional costs (EUR 399) and benefits (0.02 QALYs and 0.95 months with pain response). In the base case, the resulting ICERs (strategy A vs. strategy B) are EUR 19,845/QALY and EUR 421 per pain response. Offering all patients MR-HIFU as first-line treatment would increase the ICER by 50% (31,048 EUR/QALY). PSA showed that at a (hypothetical) willingness to pay of EUR 20,000/QALY, the probability of MR-HIFU being cost-effective was 52%. The expected value of perfect information (EVPI) for the benefit population in Germany is approximately EUR 190 Mio.

Conclusion

Although there is considerable uncertainty, the results demonstrate that introducing MR-HIFU as a treatment alternative for painful bone metastases might be cost-effective for the German SHI. The high EVPI indicate that further studies to reduce uncertainty would be worthwhile.

Unwarranted variation in radiation therapy fractionation

The adoption of hypofractionation across multiple tumour sites has been slow despite robust evidence. There is considerable unwarranted variation in practice, both within and between jurisdictions. This has been attributed to inconsistencies in guidelines, physician preference, lack of technology and differing financial incentives. Unwarranted variation in the use of hypofractionation has a tremendous effect on cost to both patients and the healthcare system. This places an unnecessary burden on patients and poorly utilises scarce healthcare resources. A collaborative effort from clinicians, patients, healthcare providers and policymakers is needed to reduce unwarranted variation in practice. This will improve quality of care both for patients and at broader healthcare system level.

Variable and fixed costs in NHS radiotherapy; consequences for increasing hypo fractionation

BACKGROUND/PURPOSE

The increased use of hypofractionated radiotherapy changes department activity. While expected to be cost-effective, departments' fixed costs may impede savings. Understanding radiotherapy's cost-drivers, to what extent these are fixed and consequences of reducing activity can help to inform reimbursement strategies.

MATERIAL/METHODS

We estimate the cost of radiotherapy provision, using time-driven activity-based costing, for five bone metastases treatment strategies, in a large NHS provider. We compare these estimations to reimbursement tariff and assess their breakdown by cost types: fixed (buildings), semi-fixed (staff, linear accelerators) and variable (materials) costs. Sensitivity analyses assess the cost-drivers and impact of reducing departmental activity on the costs of remaining treatments, with varying disinvestment assumptions.

RESULTS

The estimated radiotherapy cost for bone metastases ranges from 430.95€ (single fraction) to 4240.76€ (45 Gy in 25#). Provider costs align closely with NHS reimbursement, except for the stereotactic ablative body radiotherapy (SABR) strategy (tariff exceeding by 15.3%). Semi-fixed staff costs account for 28.1-39.7% and fixed/semi-fixed equipment/space costs 38.5-54.8% of provider costs. Departmental activity is the biggest cost-driver; reduction in activity increasing cost, predominantly in fractionated treatments. Decommissioning linear accelerators ameliorates this, although can only be realised at equipment capacity thresholds.

CONCLUSION

Hypofractionation is less burdensome to patients and long-term offers a cost-efficient mechanism to treat an increasing number of patients within existing capacity. As a large majority of treatment costs are fixed/semi-fixed, disinvestment is complex, within the life expectancy of a linac, imbalances between demand and capacity will result in higher treatment costs. With a per-fraction reimbursement, this may disincentivise delivery of hypofractionated treatments.

[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.

An Intensive Educational Intervention Significantly Improves the Adoption of Single Fractionation Radiotherapy in Uncomplicated Bone Metastases

Introduction:

An education strategy was employed in our department to increase the rate of patients with uncomplicated painful bone metastases undergoing single fractionation radiotherapy (SFRT). The purpose of this report is to analyze the results of this strategy over a 5 year period.

Materials and Methods:

In January 2015, two meetings were organized in our department. In the first, data from an audit on the current SFRT rate were shown. In the second, evidence of SFRT efficacy in the relief of pain from uncomplicated bone metastases was presented. In addition, during the weekly discussion of clinical cases, the opportunity to use the SFRT was systematically recalled. Using our institutional database, all patients treated with radiotherapy for uncomplicated painful bone metastases in the period between 2014 (year considered as a reference) and 2019 were retrieved. Data regarding treatment date (year), radiotherapy fractionation, and tumor, patients, and radiation oncologists characteristics were collected.

Results:

A total of 627 patients were included in the analysis. The rate of patients undergoing SFRT increased from 4.0% in 2014 to 63.5% in 2019 (p < 0.001). At multivariable analysis, the delivery of SFRT was significantly correlated with older patients age (>80 years), lung cancer as the primary tumor, treatment prescribed by a radiation oncologist dedicated to palliative treatments, and treatment date (2014 vs 2015–2019).

Conclusions:

This retrospective single-center analysis showed that a simple but intensive and prolonged departmental education strategy can increase the rate of patients treated with SFRT by nearly 16 times.

Adoption of single fraction radiotherapy for uncomplicated bone metastases in a tertiary centre

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Single fraction radiotherapy is feasible for uncomplicated bone metastases.

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Four-week mortality was similar between single fraction and multiple fraction.

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Our paper has the highest rate of reported single fraction radiotherapy in literature.

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Re-irradiation were higher for single fraction radiotherapy in uncomplicated bone metastases.

Background

Single-fraction radiotherapy (SFRT) offers equal pain relief for uncomplicated painful bone metastases as compared to multiple-fraction radiotherapy (MFRT). Despite this evidence, the adoption of SFRT has been poor with published rates of SFRT for uncomplicated bone metastases ranging from <10% to 70%. We aimed to evaluate the adoption of SFRT and its evolution over time following the more formal endorsement of the international guidelines in our centre starting from 2013.

Materials and methods

We performed a retrospective review of fractionation schedules at our centre for painful uncomplicated bone metastases from January 2013 until December 2017. Only patients treated with 1 × 8 Gy (SFRT-group) or 10 × 3 Gy (MFRT-group) were included. We excluded other fractionation schedules, primary cancer of the bone and post-operative radiotherapy. Uncomplicated was defined as painful but not associated with impending fracture, existing fracture or existing neurological compression. Temporal trends in SFRT/MFRT usage and overall survival were investigated. We performed a lesion-based patterns of care analysis and a patient-based survival analysis. Mann-Whitney U and Chi-square test were used to assess differences between fractionation schedules and temporal trends in prescription, with Kaplan-Meier estimates used for survival analysis (p-value <0.05 considered significant).

Results

Overall, 352 patients and 594 uncomplicated bone metastases met inclusion criteria. Patient characteristics were comparable between SFRT and MFRT, except for age. Overall, SFRT was used in 92% of all metastases compared to 8% for MFRT. SFRT rates increased throughout the study period from 85% in 2013 to 95% in 2017 (p = 0.06). Re-irradiation rates were higher in patients treated with SFRT (14%) as compared to MFRT (4%) (p = 0.046). Four-week mortality and median overall survival did not differ significantly between SFRT and MFRT (17% vs 18%, p = 0.8 and 25 weeks vs 38 weeks, p = 0.97, respectively).

Conclusions

Adherence to the international guidelines for SFRT for uncomplicated bone metastasis was high and increased over time to 95%, which is the highest reported rate in literature.

Hypofractionated radiotherapy in the real-world setting: An international ESTRO-GIRO survey

BACKGROUND AND PURPOSE

Multiple large trials have established the non-inferiority of hypofractionated radiotherapy compared to conventional fractionation. This study will determine real-world hypofractionation adoption across different geographic regions for breast, prostate, cervical cancer, and bone metastases, and identify barriers and facilitators to its use.

MATERIALS AND METHODS

An anonymous, electronic survey was distributed from January 2018 through January 2019 to radiation oncologists through the ESTRO-GIRO initiative. Predictors of hypofractionation were identified in univariable and multivariable regression analyses.

RESULTS

2316 radiation oncologists responded. Hypofractionation was preferred in node-negative breast cancer following lumpectomy (82·2% vs. 46·7% for node-positive; p < 0.001), and in low- and intermediate-risk prostate cancer (57·5% and 54·5%, respectively, versus 41·2% for high-risk (p < 0.001)). Hypofractionation was used in 32·3% of cervix cases in Africa, but <10% in other regions (p < 0.001). For palliative indications, hypofractionation was preferred by the majority of respondents. Lack of long-term data and concerns about local control and toxicity were the most commonly cited barriers. In adjusted analyses, hypofractionation was least common for curative indications amongst low- and lower-middle-income countries, Asia-Pacific, female respondents, small catchment areas, and in centres without access to intensity modulated radiotherapy.

CONCLUSION

Significant variation was observed in hypofractionation across curative indications and between regions, with greater concordance in palliation. Using inadequate fractionation schedules may impede the delivery of affordable and accessible radiotherapy. Greater regionally-targeted and disease-specific education on evidence-based fractionation schedules is needed to improve utilization, along with best-case examples addressing practice barriers and supporting policy reform.

How might financial pressures have impacted brachytherapy? A proposed narrative to explain the declines in cervical and prostate brachytherapy utilization

Rates of brachytherapy administration in the United States have declined for both cervical and prostate cancers, and we argue that the available facts suggest financial considerations are a major contributor to this issue. In this narrative, we discuss financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, consider other proposed influences, and provide suggestions for future research to understand the scope of the issue.

External Beam Irradiation in the Palliation of Bone Metastases: A Practice Analysis among Sicilian Departments of Radiation Oncology

Background

In the treatment of bone metastases, the choice of radiation fractionation, total radiation dose, delivery technique, and imaging studies before treatment varies among radiation oncologists. Surveys on this issue, using case scenarios, have been published by groups from Europe, North America, and Australia-New Zealand. Our objective was to analyze retrospectively the “real” practice in nine radiotherapy centers located in Sicily.

Method

A questionnaire including 17 items was distributed to 30 practicing radiation oncologists working in seven departments of four Sicilian cities (Messina, Catania, Ragusa and Palermo) during a meeting of the Sicilian Division of the Associazione Italians Radioterapia Oncologica (AIRO). Participants were asked to answer the questions using a card for every patient treated with external beam irradiation from 1 January to 31 December, 2000.

Results

Six centers returned the questionnaires; 332 cards were valuable for a total of 5644 responses. All six responding departments used linear accelerators for treatment delivery. The most common dose fractionation was 30 Gy in 10 fractions and the most common technique used was opposed parallel local fields. Before the start of irradiation a bone scan was performed in 325 of the 332 (98%) patients treated and CT and/or MRI was performed in 320 (96%); surprisingly, standard roentgenograms were used in only 142 of 332 patients (42.8%).

Conclusion

The “real” radiation practice for bone metastases in the region of Sicily confirms the results of the previously reported international surveys: there is a clear preference for fractionated treatment and local field therapy. The results of randomized studies, which demonstrated both the efficacy and the feasibility of a single 6–8 Gy fraction in the palliation of bone metastases, have little or no impact on the pattern of practice.

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.

Update of the systematic review of palliative radiation therapy fractionation for bone metastases

PURPOSE

Radiation therapy is an effective modality for pain management of symptomatic bone metastases. We update the previous meta-analyses of randomized trials comparing single fraction to multiple fractions of radiation therapy in patients with uncomplicated bone metastases.

METHODS

A literature search was conducted in Ovid Medline, Embase, and Cochrane Central Register. Ten new randomized trials were identified since 2010, five with adequate and appropriate data for inclusion, resulting in a total of 29 trials that were analyzed. Forest plots based on each study's odds ratios were computed using a random effects model and the Mantel-Haenszel statistic.

RESULTS

In intention-to-treat analysis, the overall response rate was similar in patients for single fraction treatments (61%; 1867/3059) and those for multiple fraction treatments (62%; 1890/3040). Similarly, complete response rates were nearly identical in both groups (23% vs 24%, respectively). Re-treatment was significantly more frequent in the single fraction treatment arm, with 20% receiving additional treatment to the same site versus 8% in the multiple fraction treatment arm (p < 0.01). No significant difference was seen in the risk of pathological fracture at the treatment site, rate of spinal cord compression at the index site, or in the rate of acute toxicity.

CONCLUSION

Single fraction and multiple fraction radiation treatment regimens continue to demonstrate similar outcomes in pain control and toxicities, but re-treatment is more common for single fraction treatment patients.

Healthcare-resource utilization associated with radiation to bone across eight European countries: Results from a retrospective study

Background

Bone metastases and lytic lesions due to multiple myeloma are common in advanced cancer and can lead to debilitating complications (skeletal-related events [SREs]), including requirement for radiation to bone. Despite the high frequency of radiation to bone in patients with metastatic bone disease, our knowledge of associated healthcare resource utilization (HRU) is limited.

Methods

This retrospective study estimated HRU following radiation to bone in Austria, the Czech Republic, Finland, Greece, Poland, Portugal, Sweden and Switzerland. Eligible patients were ≥ 20 years old, had bone metastases secondary to breast, lung or prostate cancer, or bone lesions associated with multiple myeloma, and had received radiation to bone between 1 July 2004 and 1 July 2009. HRU data were extracted from hospital patient charts from 3.5 months before the index SRE (radiation to bone preceded by a SRE-free period of ≥ 6.5 months) until 3 months after the last SRE that the patient experienced during the study period.

Results

In total, 482 patients were included. The number of inpatient stays increased from baseline by a mean of 0.52 (standard deviation [SD] 1.17) stays per radiation to bone event and the duration of stays increased by a mean of 7.8 (SD 14.8) days. Outpatient visits increased by a mean of 4.24 (SD 6.57) visits and procedures by a mean of 8.51 (SD 7.46) procedures.

Conclusion

HRU increased following radiation to bone across all countries studied. Agents that prevent severe pain and delay the need for radiation have the potential to reduce the burden imposed on healthcare resources and patients.

De Bari B, Chiesa S, Filippi AR, Gambacorta MA, D'Emilio V, Murino P, Livi L. The INTER-ROMA Project - a Survey among Italian Radiation Oncologists on Their Approach to the Treatment of Bone Metastases

Aims and background

Radiotherapy has an established palliative role for bone metastases but despite the large number of patients treated there is still controversy surrounding the optimal radiotherapy schedule to prescribe. The aim of this survey was to determine the decision patterns of Italian radiation oncologists in four different clinical cases of patients with bone metastases.

Methods and study design

During the latest national meeting of the Italian Association of Radiation Oncology (AIRO), four clinical cases were presented to attending radiation oncologists. The cases were different with respect to the histology of the primary tumor, performance status, pain before and after analgesics, tumor site, and radiological characteristics of the metastatic lesions. For each clinical case the respondents were asked to give an indication for treatment; prescribe doses, volumes and treatment field arrangements; decide whether to prescribe prophylactic supportive therapy or not; and provide information about factors that particularly influenced prescription. Finally, a descriptive statistical analysis was performed.

Results

Three hundred questionnaires were distributed to radiation oncologists attending the congress. One hundred twenty-five questionnaires were returned but only 122 (40.6%) were adequately completed and considered for the analysis. Considerable differences were observed among radiation oncologists in prescribing and delivering radiotherapy for bone metastases. There was also a notable divergence from international guidelines, which will be discussed in this report.

Conclusions

Despite the results of clinical trials, Italian radiation oncologists differ considerably in their decisions on treatment doses and volumes. National guidelines are needed in order that patients can be treated uniformly and better data will become available for evidence-based palliative radiotherapy.

The Influence of Health Insurance Policy on Radiation Oncology Physician SBRT/SABR Use Practices: A North American Survey

PURPOSE

European data suggest that 8-fraction stereotactic body radiation therapy (SBRT) regimens may be similar in efficacy with less toxicity than ≤5-fraction SBRT for central lung lesions. However, under current Centers for Medicare and Medicaid Services guidelines, SBRT in the United States (US) is reimbursed for only ≤5 fractions, whereas there are no such restrictions for reimbursement in Canada. We hypothesize that US-specific SBRT reimbursement policies influence the use of ≥5-fraction SBRT in US academic centers in comparison with comparable Canadian centers.

METHODS AND MATERIALS

A 15-question electronic survey was distributed to radiation oncologists at National Cancer Institute-designated cancer centers in the US and the 10 highest research-funded cancer centers in Canada. Fisher exact test or exact logistic regression if applicable was used, where P<.05 was considered statistically different from neutral.

RESULTS

Of the 143 radiation oncologists from 60 US cancer centers and 6 Canadian cancer centers who completed the survey (17.6% response rate), 125 routinely prescribe SBRT. Fifty percent of US physicians versus 0% of Canadian physicians indicated that there are instances when they would like to prescribe >5-fraction SBRT but prescribe ≤5 fractions because of insurance reimbursement (P=.076 and P=.001, respectively). Seventy percent (P=.006) of US radiation oncologists versus 0% (P=.001) of Canadian radiation oncologists report that SBRT clinical investigation is constrained by the insurance reimbursement. The most common reported deterrent to prescribing >5-fraction SBRT in the US was insurance reimbursement (49.5%).

CONCLUSIONS

US radiation oncologists are more likely than those in Canada to report that SBRT clinical investigation and >5-fraction SBRT use may be negatively influenced by health insurance reimbursement; this perception was not held by physicians in Canada. Health care environment may significantly affect radiation therapy decision making and practice patterns.

A review of patterns of practice and clinical guidelines in the palliative radiation treatment of uncomplicated bone metastases

BACKGROUND AND PURPOSE

Single fraction radiation treatment (SFRT) is recommended for its equivalence to multiple-fraction (MF) RT in the palliation of uncomplicated bone metastases (BM). However, adoption of SFRT has been slow.

MATERIALS AND METHODS

Literature searches for studies published following 2014 were conducted using online repositories of gray literature, Ovid MEDLINE, Embase and Embase Classic, and the Cochrane Central Register of Controlled Trials databases.

RESULTS

A total of 32 articles detailing patterns of practice and clinical practice guidelines were included for final synthesis. The majority of organizations have released high level recommendations for SFRT use in treatment of uncomplicated BM, based on evidence of non-inferiority to MFRT. There are key differences between guidelines, such as varying strengths of recommendation for SFRT use over MFRT; contraindication in vertebral sites for SFRT; and risk estimation of pathologic fractures after SFRT. Differences in guidelines may be influenced by committee composition and organization mandate. Differences in patterns of practice may be influenced by individual center policies, payment modalities and consideration of patient factors such as age, prognosis, and performance status.

CONCLUSION

Although there is some variation between groups, the majority of guidelines recommend use of SFRT and others consider it to be a reasonable alternative to MFRT.

Considerations for Quality Improvement in Radiation Oncology Therapy for Patients with Uncomplicated Painful Bone Metastases

Background: There is an increasing need for evidence-based efficiency in providing a growing amount of cancer care. One example of a quality gap is the use of multiple-fraction palliative radiation for patients with advanced cancer who have uncomplicated bone metastases; evidence suggests similar pain outcomes for treatment regimens with a lower burden of treatments. Methods: During the first phase of quality improvement work, we used RAND/UCLA appropriateness methodology to understand how radiation oncologists at one academic medical center rate the appropriateness of different treatment regimens for painful uncomplicated bone metastases. We compared radiation oncologist appropriateness ratings for radiation treatments with radiation therapy provided by these oncologists to patients with painful bone metastases between July 2012 and June 2013. Results: Appropriateness ratings showed that single-fraction (8 Gy) treatment (a low burden treatment) was consistently considered an appropriate option to treat a variety of uncomplicated bone metastases. The use of >10 fractions was consistently rated as inappropriate regardless of other factors. Eighty-one patients receiving radiation therapy for painful bone metastases during the study period had an available medical record for chart abstraction. Almost one-third of metastases were considered complicated because of a concern of spinal cord compression, a history of prior irradiation, or an associated pathological fracture. Among uncomplicated bone metastases, 25% were treated with stereotactic body radiation treatment (SBRT). Among the 54 uncomplicated bone metastases treated with conformal radiation, only one was treated with single-fraction treatment and 32% were treated with greater than 10 fractions. Conclusions: Treatment at the study site demonstrates room for improvement in providing low-burden radiation oncology treatments for patients with painful bone metastases. Choosing a radiation treatment schedule for patients with advanced cancer and painful bone metastases requires consideration of many medical and patient-centered factors. Our experience suggests that it will take more than the existence of guidelines to change practice in this area.

[Needs and financing of radiotherapy in France and Europe]

Access to high-quality and safe radiotherapy is a prerequisite to assure optimal oncology care in a multidisciplinary environment. In view of supporting long-term radiotherapy planning, actual and predicted radiotherapy needs should be put in context of the nowadays' available resources. The present article reviews the existing data on radiotherapy resources and needs, along with the prevailing reimbursement systems in the different European countries, with a specific emphasis on France. It describes potential incentives of different financing systems on clinical practice and highlights how knowledge of the cost of radiotherapy treatments, by indication and technique, is essential to support correct reimbursement, hence access to radiotherapy. It is expected that such data will help national professional and scientific radiotherapy societies across Europe in their negotiations with policy makers, with the ultimate aim to make radiotherapy accessible to all cancer patients who need it, now and in the decades to come.

Prevalence and Predictors of Inappropriate Delivery of Palliative Thoracic Radiotherapy for Metastatic Lung Cancer

BACKGROUND

High-level evidence has established well-recognized standard treatment regimens for patients undergoing palliative chest radiotherapy (RT) for stage IV non-small cell lung cancer (NSCLC), including treating with fewer than 15 fractions of RT, and not delivering concurrent chemoradiation (CRT) because of its increased toxicity and limited efficacy in the palliative setting.

METHODS

The study included patients in the National Cancer Database from 2004 to 2012 with stage IV lung cancer who received palliative chest radiation therapy. Logistic regression was performed to determine predictors of standard vs nonstandard regimens (>15 fractions or CRT). All statistical tests were two-sided.

RESULTS

There were 46 803 patients in the analysis and 49% received radiotherapy for longer than 15 fractions, and 28% received greater than 25 fractions. Approximately 19% received CRT. The strongest independent predictors of long-course RT were private insurance (odds ratio [OR] = 1.40 vs uninsured, 95% confidence interval [CI] = 1.28 to 1.53) and treatment in community cancer programs (OR = 1.49, 95% CI = 1.38 to 1.58) compared with academic research programs. The strongest factors that predicted for concurrent chemoradiotherapy were private insurance (OR = 1.38 95% CI = 1.23 to 1.54) compared with uninsured patients and treatment in community cancer programs (OR = 1.44, 95% CI = 1.33 to 1.56) compared with academic programs.

CONCLUSIONS

Approximately half of all patients with metastatic lung cancer received a higher number of radiation fractions than recommended. Patients with private insurance and treated in community cancer centers were more likely to receive longer courses of RT or CRT. This demonstrates that a substantial number of patients requiring palliative thoracic radiotherapy are overtreated and further work is necessary to ensure these patients are treated according to evidenced-based guidelines.

Incidence and treatment patterns of complicated bone metastases in a population-based radiotherapy program

INTRODUCTION

There is abundant evidence in support of single fraction (SF) radiation therapy (RT) for uncomplicated bone metastases (BoM). We sought to determine the proportion of BoM that is complicated in a population-based RT program in order to act as a potential guide for assessing SFRT utilization rates.

MATERIALS AND METHODS

A total of 3200 RT courses were prescribed to 1880 consecutive patients diagnosed with BoM in 2013. Associations between choice of RT fractionation and BoM characterization, whether complicated or not, were assessed with logistic regression.

RESULTS

The incidence of complicated BoM was 34.4%, resulting most often from adverse features of actual pathological fracture (42.1%), and neurological compromise (36.3%). Complicated BoM were most common in lung cancers (24.2%) and in the spine (68.5%), followed by extremity (15.2%) and pelvis (14.4%). SFRT was prescribed less commonly in complicated versus un-complicated BoM (39.4% vs. 70.4%; p<0.001), which was confirmed on multivariable analysis (OR 0.32; 95% CI 0.28-0.61; p<0.001).

CONCLUSIONS

This study found that 34.4% of BoM are complicated by fracture, or neurological compromise (i.e. 65.6% were un-complicated), and that they were less likely to receive SFRT. A reasonable benchmark for SFRT utilization should be at least 60%.

The optimal utilization proportion of external beam radiotherapy in European countries: An ESTRO-HERO analysis

BACKGROUND AND PURPOSE

The absolute number of new cancer patients that will require at least one course of radiotherapy in each country of Europe was estimated.

MATERIAL AND METHODS

The incidence and relative frequency of cancer types from the year 2012 European Cancer Observatory estimates were used in combination with the population-based stage at diagnosis from five cancer registries. These data were applied to the decision trees of the evidence-based indications to calculate the Optimal Utilization Proportion (OUP) by tumour site.

RESULTS

In the minimum scenario, the OUP ranged from 47.0% in the Russian Federation to 53.2% in Belgium with no clear geographical pattern of the variability among countries. The impact of stage at diagnosis on the OUP by country was rather limited. Within the 24 countries where data on actual use of radiotherapy were available, a gap between optimal and actual use has been observed in most of the countries.

CONCLUSIONS

The actual utilization of radiotherapy is significantly lower than the optimal use predicted from the evidence based estimates in the literature. This discrepancy poses a major challenge for policy makers when planning the resources at the national level to improve the provision in European countries.

Assessment of national practice for palliative radiation therapy for bone metastases suggests marked underutilization of single-fraction regimens in the United States

PURPOSE

To characterize temporal trends in the application of various bone metastasis fractionations within the United States during the past decade, using the National Cancer Data Base; the primary aim was to determine whether clinical practice in the United States has changed over time to reflect the published randomized evidence and the growing movement for value-based treatment decisions.

PATIENTS AND METHODS

The National Cancer Data Base was used to identify patients treated to osseous metastases from breast, prostate, and lung cancer. Utilization of single-fraction versus multiple-fraction radiation therapy was compared according to demographic, disease-related, and health care system details.

RESULTS

We included 24,992 patients treated during the period 2005-2011 for bone metastases. Among patients treated to non-spinal/vertebral sites (n=9011), 4.7% received 8 Gy in 1 fraction, whereas 95.3% received multiple-fraction treatment. Over time the proportion of patients receiving a single fraction of 8 Gy increased (from 3.4% in 2005 to 7.5% in 2011). Numerous independent predictors of single-fraction treatment were identified, including older age, farther travel distance for treatment, academic treatment facility, and non-private health insurance (P<.05).

CONCLUSIONS

Single-fraction palliative radiation therapy regimens are significantly underutilized in current practice in the United States. Further efforts are needed to address this issue, such that evidence-based and cost-conscious care becomes more commonplace.

Palliative radiotherapy for bone metastases from lung cancer: Evidence-based medicine?

To review current recommendations for palliative radiotherapy for bone metastases secondary to lung cancer, and to analyze surveys to examine whether global practice is evidence-based, English language publications related to best practice palliative external beam radiotherapy (EBRT) for bone metastases (BM) from lung cancer were sought via literature search (2003-2013). Additional clinical practice guidelines and consensus documents were obtained from the online Standards and Guidelines Evidence Directory. Eligible survey studies contained hypothetical case scenarios which required participants to declare whether or not they would administer palliative EBRT and if so, to specify what dose fractionation schedule they would use. There is no convincing evidence of differential outcomes based on histology or for spine vs non-spine uncomplicated BM. For uncomplicated BM, 8Gy/1 is widely recommended as current best practice; this schedule would be used by up to 39.6% of respondents to treat a painful spinal lesion. Either 8Gy/1 or 20Gy/5 could be considered standard palliative RT for BM-related neuropathic pain; 0%-13.2% would use the former and 5.8%-52.8% of respondents the latter (range 3Gy/1-45Gy/18). A multifraction schedule is the approach of choice for irradiation of impending pathologic fracture or spinal cord compression and 54% would use either 20Gy/5 or 30Gy/10. Survey results regarding management of complicated and uncomplicated BM secondary to lung cancer continue to show a large discrepancy between published literature and patterns of practice.

International patterns of practice in radiotherapy for bone metastases: A review of the literature

PURPOSE

Radiation therapy is the standard treatment for symptomatic bone metastases. Several randomized control trials and meta-analyses have concluded a similar efficacy in pain relief when comparing single versus multiple fraction regimes. However, there continues to be reluctance to conform to published guidelines that recommend a single treatment for the palliation of painful bone metastases. The purpose of this literature review is to summarize international patterns of practice, and to determine if guidelines recommending single fraction treatment have been implemented in clinical care.

METHODS

A literature search was conducted in Ovid Medline, Embase, and Cochrane Central. Search words included, 'bone metastases', 'radiation therapy', 'radiotherapy', 'patterns of practice', and 'dose fractionation'. Both prospective and retrospective studies that investigated the prescription of radiotherapy to bone metastases using actual patient databases were included. Articles were excluded if they investigated hypothetical scenarios.

RESULTS

Six hundred and thirteen results were generated from the literature search. Twenty-six articles met the inclusion criteria. Of these, 11 were Canadian, 8 were European, 6 were American, and 1 was Australian. The use of single fraction radiotherapy (SFRT) ranged from 3% to 75%, but was generally lower in American studies. Choice of fractionation depended on a variety of factors, including patient age, prognosis, site of irradiation, and physician experience.

CONCLUSION

Despite the publication of robust randomized control trials, meta-analyses, and clinical practice guidelines recommending the use of a single treatment to palliate uncomplicated bone metastasis, SFRT is internationally underutilized.

Use of single- versus multiple-fraction palliative radiation therapy for bone metastases: population-based analysis of 16,898 courses in a Canadian province

PURPOSE

There is abundant evidence that a single fraction (SF) of palliative radiation therapy (RT) for bone metastases is equivalent to more protracted and costly multiple fraction courses. Despite this, there is low utilization of SFRT internationally. We sought to determine the utilization of SFRT in a population-based, publicly funded health care system.

METHODS AND MATERIALS

All consecutive patients with bone metastases treated with RT during 2007 to 2011 in British Columbia (BC) were identified. Associations between utilization of SFRT and patient and provider characteristics were investigated.

RESULTS

A total of 16,898 courses of RT were delivered to 8601 patients. SFRT was prescribed 49% of the time. There were positive relationships among SFRT utilization and primary tumor group (P<.001; most commonly in prostate cancer), worse prognosis (P<.001), increasing physician experience (P<.001), site of metastases (P<.001; least for spine metastases), and area of training (P<.001; most commonly for oncologists trained in the United Kingdom). There was wide variation in the prescription of SFRT across 5 regional cancer centers, ranging from 25.5% to 73.4%, which persisted after controlling for other, potentially confounding factors (P<.001).

CONCLUSIONS

The large variability in SFRT utilization across BC Cancer Agency (BCCA) cancer centers suggests there is a strong cultural effect, where physicians' use of SFRT is influenced by their colleagues' practice. SFRT use in BC was similar to that in other Canadian and western European reports but strikingly higher than in the United States. Further work is needed to standardize SFRT prescribing practices internationally for this common indication for RT, with the potential for huge health system cost savings and substantial improvements in patients' quality of life.

Evaluating the attendance of medical staff and room occupancy during palliative radiotherapy

INTRODUCTION

Attendance of staff and use of resources during treatment have an impact on costs. For palliative radiotherapy, no reliable data are available on the subject. Therefore, the measurement of selected variables (staff absorbance and room occupancy) based on daily palliative irradiation was the aim of our prospective study. The analysis is part of a larger study conducted by the German Society of Radiation Oncology (DEGRO).

PATIENTS, MATERIAL, AND METHODS

A total of 172 palliative radiation treatments were followed up prospectively between October 2009 and March 2010. The study was performed at two experienced radiotherapy departments (Herne and Bielefeld) and evaluated the attendance of medical personnel and room occupancy related to the selected steps of the treatment procedure: treatment planning and daily application of radiation dose.

RESULTS

Computed tomography for treatment planning engaged the unit for 19 min (range: 17-22 min). The localization of target volume required on average 28 min of a technician's working time. The mean attendance of the entire staff (radiation oncologist, physicist, technician) for treatment planning was 159 min, while the total room occupancy was 140 min. Depending on the type of treatment, the overall duration of a radiotherapy session varied on average between 8 and 18 min. The staff was absorbed by the first treatment session (including portal imaging) for 8-27 min. Mean room occupancy was 18 min (range: 6-65 min). The longest medical staff attendance was observed during an initial irradiation session (mean: 11 min). Radiotherapy sessions with weekly performed field verifications occupied the rooms slightly longer (mean: 10 min, range: 4-25 min) than daily radiotherapy sessions (mean: 9 min, range: 3-29 min). We observed that the patients' symptoms, their condition, and their social environment confounded the time schedule.

CONCLUSIONS

Target localization, treatment planning, and performance of palliative radiotherapy absorb resources to an extent comparable to nonpalliative treatment. Because of unexpected events, the time schedule before and during radiotherapy may reveal strong interindividual variability.

A survey of patterns of practice on palliative radiation therapy for bone metastasis in Korea

PURPOSE

The aim of this study was to understand the practice patterns of palliative radiation therapy for bone metastasis in Korea among Korean radiation oncologists by survey and to determine the decision factors affecting the prescription of radiation therapy fractionation schedules.

METHODS

An Internet-based survey was performed from October 5 to October 23, 2009, among 177 active full members of the Korean Society for Radiation and Oncology (KOSRO). The survey questionnaire included general information about the respondent, three types of clinical scenario, depending on the life expectancy of the patients, and the decision factors that affected the prescription of a radiation therapy schedule.

RESULTS

The most prescribed schedule was 30 Gy in 10 fractions regardless of the life expectancy of the patient. Also, it was found that a single fraction was seldom prescribed routinely in Korea. An increasing number prescribed fewer than 10 fractions as the life expectancy shortened; however, the prescription rate of a single fraction was still low. The general performance (and/or accompanying diseases) of patients and the life expectancy were the most considered factors in deciding the prescription of radiation therapy.

CONCLUSIONS

Despite the abundant evidence supporting the equivalence of single- and multi-fraction radiation therapy, still, most Korean radiation oncologists continue to prescribe multi-fraction schedules depending on the general performance and life expectancy of the patients. Thus, we confirmed that there was a gap between evidence and practice, and treatment prescriptions can be strongly affected by decision factors other than published literature results.

Patterns of practice in the prescription of palliative radiotherapy for the treatment of bone metastases at the Rapid Response Radiotherapy Program between 2005 and 2012

OBJECTIVE

We examined whether patterns of practice in the prescription of palliative radiation therapy for bone metastases had changed over time in the Rapid Response Radiotherapy Program (rrrp).

METHODS

After reviewing data from August 1, 2005, to April 30, 2012, we analyzed patient demographics, diseases, organizational factors, and possible reasons for the prescription of various radiotherapy fractionation schedules. The chi-square test was used to detect differences in proportions between unordered categorical variables. Univariate logistic regression analysis and the simple Fisher exact test were also used to determine the factors most significant to choice of dose-fractionation schedule.

RESULTS

During the study period, 2549 courses of radiation therapy were prescribed. In 65% of cases, a single fraction of radiation therapy was prescribed, and in 35% of cases, multiple fractions were prescribed. A single fraction of radiation therapy was more frequently prescribed when patients were older, had a prior history of radiation, or had a prostate primary, and when the radiation oncologist had qualified before 1990.

CONCLUSIONS

For patients with bone metastasis, a single fraction of radiation therapy was prescribed with significantly greater frequency.

Palliative radiation therapy practice in patients with metastatic non-small-cell lung cancer: a Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study

PURPOSE

Randomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression.

RESULTS

Of 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associated with younger age at diagnosis and receipt of chemotherapy and surgery to metastatic sites. Among patients receiving palliative bone RT, only 6% received single-fraction treatment. Among patients receiving palliative chest RT, 42% received more than 20 fractions. Patients treated in integrated networks were more likely to receive lower doses and fewer fractions to the bone and chest.

CONCLUSION

When palliative RT is used in patients with metastatic NSCLC, a substantial proportion of patients receive a greater number of treatments and higher doses than supported by current evidence, suggesting an opportunity to improve care delivery.

Patterns of practice in palliative radiotherapy for painful bone metastases: a survey in Japan

PURPOSE

To determine the current patterns of practice in Japan and to investigate factors that may make clinicians reluctant to use single-fraction radiotherapy (SF-RT).

METHODS AND MATERIALS

Members of the Japanese Radiation Oncology Study Group (JROSG) completed an Internet-based survey and described the radiotherapy dose fractionation they would recommend for four hypothetical cases describing patients with painful bone metastasis (BM). Case 1 described a patient with an uncomplicated painful BM in a non-weight-bearing site from non-small-cell lung cancer. Case 2 investigated whether management for a case of uncomplicated spinal BM would be different from that in Case 1. Case 3 was identical with Case 2 except for the presence of neuropathic pain. Case 4 investigated the prescription for an uncomplicated painful BM secondary to oligometastatic breast cancer. Radiation oncologists who recommended multifraction radiotherapy (MF-RT) for Case 2 were asked to explain why they considered MF-RT superior to SF-RT.

RESULTS

A total of 52 radiation oncologists from 50 institutions (36% of JROSG institutions) responded. In all four cases, the most commonly prescribed regimen was 30 Gy in 10 fractions. SF-RT was recommended by 13% of respondents for Case 1, 6% for Case 2, 0% for Case 3, and 2% for Case 4. For Case 4, 29% of respondents prescribed a high-dose MF-RT regimen (e.g., 50 Gy in 25 fractions). The following factors were most often cited as reasons for preferring MF-RT: "time until first increase in pain" (85%), "incidence of spinal cord compression" (50%), and "incidence of pathologic fractures" (29%).

CONCLUSIONS

Japanese radiation oncologists prefer a schedule of 30 Gy in 10 fractions and are less likely to recommend SF-RT. Most Japanese radiation oncologists regard MF-RT as superior to SF-RT, based primarily on the time until first increase in pain.

Point: short-course radiation therapy is preferable in the neoadjuvant treatment of rectal cancer

There are 2 types of neoadjuvant radiation regimens accepted as standard for resectable rectal cancer: short-course (5 × 5 Gy) radiation therapy alone with immediate surgery and long-course combined chemoradiation therapy with delayed surgery. A Polish randomized study (n = 312) and an Australian randomized study (n = 326) compared these 2 schedules. Both trials showed a lower rate of early adverse effects using a short-course radiation regimen and no differences in long-term oncologic outcomes and late toxicity rates between groups. The small number of fractions makes short-course radiation less expensive and more convenient than chemoradiation therapy. These facts indicate that short-course radiation is preferable to chemoradiation for resectable cancers. Additionally, short-course preoperative radiation with a long interval to surgery is a valuable option for patients unfit for chemotherapy, with unresectable cancer or with a small tumor that is amenable to local excision. Moreover, short-course radiation enables the intensification of both radiotherapy and chemotherapy in patients with metastatic rectal cancer with potentially resectable synchronous metastatic disease.

International variations in radiotherapy fractionation for bone metastases: geographic borders define practice patterns?

Although it may be argued that single fraction (SF) radiotherapy (RT) should be regarded as the standard palliative treatment for pain due to uncomplicated bone metastases, its widespread clinical use is still underexploited. In this chapter, the authors discuss a number of surveys investigating doctors and patients' preferences for palliative RT schedules, discuss the possible reasons for this phenomenon, and suggest potential strategies to increase the use of SF.

International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice?

PURPOSE

Multiple randomized controlled trials have demonstrated the equivalence of multifraction and single-fraction (SF) radiotherapy for the palliation of painful bone metastases (BM). However, according to previous surveys, SF schedules remain underused. The objectives of this study were to determine the current patterns of practice internationally and to investigate the factors influencing this practice.

METHODS AND MATERIALS

The members of three global radiation oncology professional organizations (American Society for Radiology Oncology [ASTRO], Canadian Association of Radiation Oncology [CARO], Royal Australian and New Zealand College of Radiologists) completed an Internet-based survey. The respondents described what radiotherapy dose fractionation they would recommend for 5 hypothetical cases describing patients with single or multiple painful BMs from breast, lung, or prostate cancer. Radiation oncologists rated the importance of patient, tumor, institution, and treatment factors, and descriptive statistics were compiled. The chi-square test was used for categorical variables and the Student t test for continuous variables. Logistic regression analysis identified predictors of the use of SF radiotherapy.

RESULTS

A total of 962 respondents, three-quarters ASTRO members, described 101 different dose schedules in common use (range, 3 Gy/1 fraction to 60 Gy/20 fractions). The median dose overall was 30 Gy/10 fractions. SF schedules were used the least often by ASTRO members practicing in the United States and most often by CARO members. Case, membership affiliation, country of training, location of practice, and practice type were independently predictive of the use of SF. The principal factors considered when prescribing were prognosis, risk of spinal cord compression, and performance status.

CONCLUSION

Despite abundant evidence, most radiation oncologists continue to prescribe multifraction schedules for patients who fit the eligibility criteria of previous randomized controlled trials. Our results have confirmed a delay in the incorporation of evidence into practice for palliative radiotherapy for painful bone metastases.