Palliative radiotherapy for patients with bone metastases: survey of primary care physicians

Prostate Cancer with Bone Metastases: Addressing Chronic Pain from the Perspective of the Radiation Oncology Nurse Practitioner

OBJECTIVES

To discuss the symptom burden experienced among patients with castrate-resistant prostate cancer and bone metastases and the role of the oncology nurse practitioner in evaluation for palliative radiotherapy.

DATA SOURCES

These include PubMed, international consensus documents, and clinician experience.

CONCLUSION

Men with advanced prostate cancer may live for several years after diagnosis of bone metastases; however, pain and other difficult symptoms are problematic. Pain is effectively treated with palliative radiotherapy, but careful assessment and intervention of other difficult symptoms must be addressed over time.

IMPLICATIONS FOR NURSING PRACTICE

Nurse practitioners in radiation oncology should be well-versed in the disease trajectory of this patient population. Careful symptom inquiry and comprehensive physical examination is a key responsibility. Palliative radiotherapy, alongside analgesics and supportive care measures, can effectively reduce symptoms and improve quality of life in men with prostate cancer metastatic to bone.

What is access to radiation therapy? A conceptual framework and review of influencing factors

OBJECTIVES

Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'.

METHODS

Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014.

RESULTS

The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation.

CONCLUSION

'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.

Barriers to radiotherapy utilisation in New South Wales Australia: Health professionals' perceptions of impacting factors

INTRODUCTION

Utilisation of radiation therapy (RT) in Australia is below recommended evidence-based benchmarks. Barriers to the referral of patients for RT and the uptake of RT by patients may be affecting RT utilisation. The current study aimed to examine health professionals' (HPs) perceptions of potential barriers to RT referral and uptake.

METHODS

A custom survey was developed to assess perceptions regarding the degree to which a range of issues affect decisions regarding RT. Hard copy surveys were disseminated to HPs involved in the care of cancer patients across New South Wales (NSW): medical, radiation and surgical oncologists, physicians (including palliative care), and general practitioners with an interest in oncology. Electronic versions of the survey were disseminated via oncology multidisciplinary teams and professional networks at participating hospitals.

RESULTS

Two hundred fifty-three HPs participated via hard copy (n = 208) or electronic (n = 45) surveys. Two-thirds of HPs perceived acute side effects of RT, their management and impact on daily commitments, as well as fear and anxiety about RT, to exert moderate to significant influence on RT decisions. Treatment-related travel, need for accommodation and relocation were also perceived by 64% of HPs to do the same. Over half of HPs rated concern regarding late effects of RT, disruption to family and work life, and the ability to organise family and work commitments around RT, as moderate to significant influences on RT uptake.

CONCLUSION

Perceptions of HPs in NSW reveal potential important influencers of RT decisions by patients and clinicians. An understanding of these additional issues and their actual impact on RT-related decisions may inform future interventions to improve RT access and utilisation.

Utilization of radiotherapy services by a palliative care unit: pattern and implication

BACKGROUND

The role of radiotherapy in palliation is well recognized. Analyzing referrals from an inpatient palliative care unit (PCU) to the radiation oncology (RO) service may help in planning palliative care (PC) services and educational programs.

OBJECTIVE

To determine the pattern and rate of referrals from a PCU to the RO service at a tertiary oncology facility in Saudi Arabia.

METHODS

Referrals from the PCU to the RO service were prospectively identified over the period beginning November 27, 2007 and ending March 9, 2011. The appropriateness of referrals was determined by 2 radiation oncologists.

RESULTS

Of the 635 cancer admissions to the PCU, 25 (3.9%) referrals to RO were made, and 32 sites were irradiated. All patients had a poor performance status (ECOG > or = 3). The most common areas irradiated were vertebrae (40.6%), pelvis (18.7%) and other bony structures (28.1%). Pain control was the most frequent reason for referral (87.5%). Only one referral was regarded by the RO service as inappropriate, indicating that 96% of the referrals were appropriate. The mean time lapse between referral and starting radiation was 4 +/- 3.6 days. A total of 75% of the patients died in the PCU within a median of 30 days post radiotherapy.

CONCLUSION

The small minority of patients in the PCU referred for radiotherapy were deemed appropriate referrals by the radiation oncologists despite their poor performance status and limited time remaining. When planning a PCU with similar admission criteria, the availability of a radiotherapy facility in close proximity may not be a priority.

Barriers to accessing radiation therapy in Canada: a systematic review

INTRODUCTION

Radiation therapy (RT) is effective treatment for curing and palliating cancer, yet concern exists that not all Canadians for whom RT is indicated receive it. Many factors may contribute to suboptimal use of RT. A review of recent Canadian literature was undertaken to identify such barriers.

METHODS

MEDLINE, CINAHL, and EMBase databases were used to search keywords relating to barriers to accessing or utilizing RT in Canada. Collected abstracts were reviewed independently. Barriers identified in relevant articles were categorized as relating to the health systems, patient socio-demographic, patient factors, or provider factors contexts and thematic analysis performed for each context.

RESULTS

535 unique abstracts were collected. 75 met inclusion criteria. 46 (61.3%) addressed multiple themes. The most cited barriers to accessing RT when indicated were patient age (n = 26, 34.7%), distance to treatment centre (n = 23, 30.7%), wait times (n = 22, 29.3%), and lack of physician understanding about the use of RT (n = 16, 21.6%).

CONCLUSIONS

Barriers to RT are reported in many areas. The role of provider factors and the lack of attention to patient fears and mistrust as potential barriers were unexpected findings demanding further attention. Solutions should be sought to overcome identified barriers facilitating more effective cancer care for Canadians.

Patterns of care and course of symptoms in palliative radiotherapy: a multicenter pilot study analysis

BACKGROUND AND PURPOSE

To evaluate patterns of care as well as effectiveness and side effects of palliative treatment in four German radiation oncology departments.

PATIENTS AND METHODS

All referrals in four German radiation oncology departments (two university hospitals, one academic hospital, one private practice) were prospective documented for 1 month in 2008 (2 months at one of the university hospitals). In palliatively irradiated patients, treatment aims and indications as well as treated sites and fractionation schedules were recorded. In addition, symptoms and side effects were analyzed with standardized questionnaires before and at the end of radiotherapy.

RESULTS

During the observation period, 603 patients underwent radiation therapy in the four centers and 153 (24%, study population) were treated with palliative intent. Within the study, patients were most frequently treated for bone (34%) or brain (27%) metastases. 62 patients reported severe or very severe pain, 12 patients reported severe or very severe dyspnea, 27 patients reported neurological deficits or signs of cranial pressure, and 43 patients reported a poor or very poor sense of well-being. The most frequent goals were symptom relief (53%) or prevention of symptoms (46%). Life prolongation was intended in 37% of cases. A wide range of fractionation schedules was applied with total doses ranging from 3-61.2 Gy. Of the patients, 73% received a slightly hypofractionated treatment schedule with doses of > 2.0 Gy to ≤ 3.0 Gy per fraction and 12% received moderate to highly hypofractionated therapy with doses of > 3.0 Gy to 8.0 Gy. Radiation therapy led to a significant improvement of well-being (35% of patients) and reduction of symptoms, especially with regard to pain (66%), dyspnea (61%), and neurological deficits (60%). Therapy was very well tolerated with only 4.5% grade I or II acute toxicities being observed. Unscheduled termination was observed in 19 patients (12%).

CONCLUSIONS

Palliative radiation therapy is effective in reducing symptoms, increases subjective well-being, and has minimal side effects. More studies are necessary for subgroup analyses and for clarifying the different goals in palliative radiotherapy.

Knowledge and utilization of palliative radiotherapy by pediatric oncologists

Background and Purpose

Palliative radiotherapy (prt) is a routine part of oncology care in adult patients, but it is used much less frequently among children with incurable cancer. We surveyed Canadian pediatric oncologists to learn about their knowledge and use of prt and to identify potential barriers to referral.

Methods

A 13-item questionnaire assessing prt knowledge and utilization was sent to 80 Canadian pediatric oncologists.

Results

The survey completion rate was 80%, with most respondents being providers of palliative care for children and making referrals for prt. Although 62% had received training in radiation oncology, only 28% had received formal palliative care training. Respondents with palliative care training were found to be significantly more knowledgeable about prt and were more likely to refer children for prt (p < 0.01). Only 59% of respondents thought that they had adequate knowledge about the indications for prt. A positive correlation was found between knowledge about the indications for prt and referral for treatment (p < 0.01). Among survey respondents, 51% believed that prt was underutilized, and the perceived barriers to prt referral included patient or family reluctance, distance to the cancer centre, belief that prt has little impact on quality of life, and concerns about toxicity.

Conclusions

Palliative radiotherapy is considered to be underutilized among children. This situation appears to be related, in part, to inadequate knowledge and training among pediatric oncologists, suggesting that more emphasis needs to be placed on pediatric palliative care education.

Variation in the use of palliative radiotherapy at end of life: examining demographic, clinical, health service, and geographic factors in a population-based study

Palliative radiotherapy (PRT) can improve quality of life for people dying of cancer. Variation in the delivery of PRT by factors unrelated to need may indicate that not all patients who may benefit from PRT receive it. In this study, 13,494 adults who died of cancer between 2000 and 2005 in Nova Scotia, Canada, were linked to radiotherapy records. Multivariate logistic regression was used to examine the relationships among demographic, clinical, service, and geographic variables, and PRT consultation and treatment. Among the decedents, 4188 (31.0%) received PRT consultation and 3032 (22.3%) treatment. PRT declined with increased travel time and community deprivation. Females, older persons, and nursing home residents also had lower PRT rates. Variations were observed by cancer site and previous oncology care. Variations in PRT use should be discussed with referring physicians, and improved means of access to PRT considered. Benchmarks for optimal rates of PRT are needed.