Palliative radiotherapy: when is it worth it and when is it not? Cancer J. 2010;16:473-482. [PMID: 20890143 DOI: 10.1097/ppo.0b013e3181f28b4d]

Analysis of Oncology and Radiation Therapy Representation on the National Board of Medical Examiners Official Practice Material for the United States National Standardized Medical Board Examinations

Radiation therapy (RT) is a critical component of multidisciplinary cancer care, but has inconsistent curricular exposure. We characterize the radiation oncology (RO) content on the standardized undergraduate medical examinations by comparing its context and prevalence with other domains in oncology. National Board of Medical Examiners (NBME) self-assessments and sample questions for the United States Medical Licensing Exam (USMLE) Steps 1-3 and NBME clinical science shelf examinations were accessed (n = 3878). Questions were inductively analyzed for content pertaining to oncology and treatment modalities of RT, systemic therapy (ST), and surgical intervention (SI). Questions were coded using USMLE Physician Tasks/Competencies and thematic analysis. Descriptive statistics and analyses using the Kruskal-Wallis test are reported. A total of 337 questions (8.6%) within the USMLE and shelf exams included oncology content, with 101 questions (2.6%) referencing at least one cancer treatment modality (n = 35 RT, 45 ST, 57 SI). Treatment questions were more common on USMLE Step 2 CK (n = 35/101, 32%) compared to Step 1 (n = 23/101, 23%) and Step 3 (n = 8/101, 8%) (p < 0.001). RT was significantly less likely to be the correct answer (2/35, 6%) compared to ST (4/45, 9%) and SI (18/57, 32%) (p = 0.003). Therapeutic oncology questions are uncommon on the examination material, with an under-representation of radiation-related content, and contextual bias favoring surgical approaches. We advocate for greater RO involvement in the content creation of such examinations to help trainees better understand multidisciplinary cancer care.

Overview of Radiation Therapy in the Management of Localized and Metastatic Prostate Cancer

PURPOSE OF REVIEW

The goal is to describe the evolution of radiation therapy (RT) utilization in the management of localized and metastatic prostate cancer.

RECENT FINDINGS

Long term data for a variety of hypofractionated definitive RT dose-fractionation schemes has matured, allowing patients and providers many standard-of-care options to choose from. Post-prostatectomy, adjuvant RT has largely been replaced by an early salvage approach. Multiparametric MRI and PSMA PET have enabled increasingly targeted RT delivery to the prostate and oligometastatic tumors. Areas of active investigation include determining the value of proton beam therapy and perirectal spacers, and optimally incorporate genomic tumor profiling and next generation hormonal therapies with RT in the curative setting. The use of radiation therapy to treat prostate cancer is rapidly evolving. In the coming years, there will be continued improvements in a variety of areas to enhance the value of RT in multidisciplinary prostate cancer management.

Radiotherapy and palliative care outpatient clinic: a new healthcare integrated model in Italy

BACKGROUND

On the basis of substantial evidence demonstrate that palliative care combined with standard care improves patient, caregiver, and society outcomes, we have developed a new healthcare model called radiotherapy and palliative care (RaP) outpatient clinic were a radiation oncologist and a palliative care physician make a joint evaluation of advanced cancer patients.

METHODS

We performed a monocentric observational cohort study on advanced cancer patients referred for evaluation at the RaP outpatient clinic. Measures of quality of care were carried out.

RESULTS

Between April 2016 and April 2018, 287 joint evaluations were performed and 260 patients were evaluated. The primary tumor was lung in 31.9% of cases. One hundred fifty (52.3%) evaluations resulted in an indication for palliative radiotherapy treatment. In 57.6% of cases was used a single dose fraction of radiotherapy (8 Gy). All the irradiated cohort completed the palliative radiotherapy treatment. An 8% of irradiated patients received the palliative radiotherapy treatment in the last 30 days of life. A total of 80% of RaP patients received palliative care assistance until the end of life.

CONCLUSION

At the first descriptive analysis, the radiotherapy and palliative care model seem to respond to the need of multidisciplinary approach in order to obtain an improvement on quality of care for advanced cancer patients.

[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.

Single-institution analysis of the prevalence, indications and outcomes of end-of-life radiotherapy

•

Survival prognostication and patient selection remain challenging tasks.

•

End-of-life radiotherapy until one week before death showed a patient benefit.

•

Treatment prescribed within one week of death often had to be discontinued.

•

Therapy needs to take into account patient preferences for the last phase of life.

Background

Radiotherapy plays an important role for symptom control in advanced stage cancer patients. Yet patients need to be carefully selected, and its use and benefits must be weighed against time spent under treatment and patient priorities in the last phase of life. In this study, we assess prevalence, indications and outcomes of radiotherapy close to death.

Methods

We screened all radiotherapy treatments performed at the Department of Radiation Oncology of the University Hospital Zurich between January 2010 and December 2019 to identify those which occurred near patients’ end-of-life. Analyzed data was extracted from the database of the Comprehensive Cancer Center Zurich, the treatment planning system Aria® and the electronical medical records system KISIM®.

Results

Within 60 days of death, 377 radiotherapy courses were prescribed to 280 patients, which constitutes 3.4% of all radiotherapy courses administered over the last decade at our department. Within 60–31, 30–8, and 7–0 days to death 164, 159, and 54 radiotherapy courses were prescribed, respectively. The most frequent treatment sites were brain (N = 122, 32%) and bone (N = 119, 32%), and there was no statistically significant difference in treatment site between the three sub-groups. The most common regimen was 10x3Gy (N = 130, 35%) in all three sub-groups (p = 0.23). Radiotherapy finished more than one week before death was associated with high completion rates (>80%) and treatment benefit (>55%).

Conclusion

Patient selection and survival prognostication remains challenging for radiation oncologists. While radiotherapy achieved high completion and success rates until one week before death, treatment within one week of death should be restricted to carefully selected patients or avoided altogether.

Care Disparities Across the Health Care Continuum for Older Adults: Lessons From Multidisciplinary Perspectives

Older adults comprise a considerable proportion of patients with cancer in the world. Across multiple cancer types, cancer treatment outcomes among older age groups are often inferior to those among younger adults. Cancer care for older individuals is complicated by the need to adapt treatment to baseline health, fitness, and frailty, all of which vary widely within this age group. Rates of social deprivation and socioeconomic disparities are also higher in older adults, with many living on reduced incomes, further compounding health inequality. It is important to recognize and avoid undertreatment and overtreatment of cancer in this age group; however, simply addressing this problem by mandating standard treatment of all would lead to harms resulting from treatment toxicity and futility. However, there is little high-quality evidence on which to base these decisions, because older adults are poorly represented in clinical trials. Clinicians must recognize that simple extrapolation of outcomes from younger age cohorts may not be appropriate because of variance in disease stage and biology, variation in fitness and treatment tolerance, and reduced life expectancy. Older patients may also have different life goals and priorities, with a greater focus on quality of life and less on length of life at any cost. Health care professionals struggle with treatment of older adults with cancer, with high rates of variability in practice between and within countries. This suggests that better national and international recommendations that more fully address the needs of this special patient population are required and that primary research focused on the older age group is urgently required to inform these guidelines.

Index and Nonindex Pain Endpoints in Radiation Therapy for Painful Tumors: A Secondary Analysis of a Prospective Observational Study

Purpose

Improving pain interference in daily activities, rather than mere pain reduction, is a desirable endpoint for palliative radiation therapy. The association between pain response and pain interference has been studied almost exclusively in patients with painful bone metastases (PBMs), whereas nonindex pain has scarcely been explored in palliative radiation therapy. We investigated whether index and nonindex pain endpoints are associated with pain interference changes in patients with both PBMs and painful non-bone-metastasis tumors (PNTs).

Methods and Materials

Brief pain inventory data collected at baseline and at 2 months post-treatment were used to calculate differences in pain interference scores. Pain response in terms of the index pain was assessed using the international consensus endpoint. Patients were diagnosed with predominance of other pain (POP) if nonindex pain of malignant or unknown origin was present and had a greater pain score than the index pain.

Results

Of 302 patients, 127 (42%) had PBMs and 175 (58%) had PNTs. The median pain interference score, which is based on the mean of the 7 subscale items, decreased to a greater extent among responders than among nonresponders (PBM group: –3.43 vs –0.57 [P = .005]; PNT group: –2.43 vs –0.29 [P < .001]). Moreover, patients without POP experienced a greater reduction in their median pain interference score than did those with POP (PBM group: –2.71 vs +0.43 [P = .004]; PNT group: –2.00 vs +1.57 [P = .007]). The Jonckheere-Terpstra test showed a significant trend across 4 pain response categories in patients with PBMs and those with PNTs (P < .001 for both).

Conclusions

The index and nonindex pain endpoints were positively and negatively associated with improvement in pain interference, respectively. There was no apparent difference between patients with PBMs and PNTs in terms of the associations of these endpoints with pain interference.

Factors associated with the receipt and completion of whole brain radiation therapy among older adults in the United States from 2010-2013

INTRODUCTION

Whole brain radiation therapy (WBRT) is widely used to treat patients with brain metastases. However, there is debate regarding its utility in patients with poor prognoses. In this study, we sought to characterize the use of WBRT in the United States, especially in adults aged 55 and above.

MATERIAL AND METHODS

Patients with brain metastases were identified using the National Cancer Database between 2010 and 2013. The receipt and completion of WBRT with various patient factors were correlated using multivariable logistic regression.

RESULTS

28,422 patients with brain metastases were identified, 23,362 of whom were aged 55 or above. 14,845 patients received WBRT and 12,310 patients completed treatment. Among adults aged 55 and above, 11,945 patients received WBRT, and 9812 patients completed treatment. Patients aged 60 and above were less likely to receive WBRT, while those aged 65 and above were less likely to complete WBRT.

DISCUSSION

These results suggest that WBRT may be over-utilized in the United States, especially among older adults. Better interventions to improve pre-WBRT decision-making in this population are needed to select patients who might derive benefit.

A Video Decision Aid Improves Informed Decision Making in Patients With Advanced Cancer Considering Palliative Radiation Therapy

CONTEXT

Advanced cancer patients have unrecognized gaps in their understanding about palliative radiation therapy (PRT).

OBJECTIVES

To build a video decision aid for hospitalized patients with advanced cancer referred for PRT and prospectively test its efficacy in reducing decisional uncertainty, improving knowledge, increasing treatment readiness and readiness for palliative care consultation, and its acceptability among patients.

METHODS

Forty patients with advanced cancer hospitalized at Memorial Sloan Kettering Cancer Center watched a video decision aid about PRT and palliative care. Patients' conceptual and logistical knowledge of PRT, decisional uncertainty, treatment readiness, and readiness for palliative care consultation were assessed before and after watching the video with a six-item knowledge survey, the decisional uncertainty subscale of the Decisional Conflict Scale, and Likert instruments to assess readiness to accept radiation treatment and/or palliative care consultation, respectively. A postvideo survey assessed the video's acceptability among patients.

RESULTS

After watching the video, decisional uncertainty was reduced (28.3 vs. 21.7; P = 0.02), knowledge of PRT improved (60.4 vs. 88.3; P < 0.001), and PRT readiness increased (2.0 vs. 1.3; P = 0.04). Readiness for palliative care consultation was unchanged (P = 0.58). Patients felt very comfortable (70%) watching the video and would highly recommend it (75%) to others.

CONCLUSION

Among hospitalized patients with advanced cancer, a video decision aid reduced decisional uncertainty, improved knowledge of PRT, increased readiness for PRT, and was well received by patient viewers.

A targeted needs assessment to improve referral patterns for palliative radiation therapy

Radiation therapy (RT) can effectively palliate a variety of symptoms in patients with metastatic cancer, using relatively low doses that infrequently cause major side effects. However, palliative radiation is often underutilized and sub-optimally implemented. In this study, we surveyed the Society of Palliative Radiation Oncology (SPRO) membership to identify barriers to appropriate referral for palliative RT that they encounter in their practice, and identify specific groups of physicians who radiation oncologists believed would benefit most from further education on when to refer patients. A total of 28 radiation oncologists responded to the survey with a response rate of 20.5%. On average, participants felt that referrals for palliative RT were inappropriately delayed 46.5% [standard deviation (STD) 20.2%] of the time. The most common barrier to referral for medical oncologists was thought to be potential interference with systemic therapy (33%); for primary care physicians and surgeons it was a lack of knowledge about the benefit (42%), and for palliative care physicians it was concern for patient convenience (25%). For brain metastases and spinal cord compression radiation oncology was felt to be part of the initial referral sequence more than 50% of the time, but less so for thoracic airway obstruction/bleeding (38%), esophageal obstruction (16%), or urinary obstruction/bleeding (8%), where another subspecialist was more often consulted first. Primary care, geriatric medicine, and emergency medicine were considered among the least knowledgeable specialties about palliative radiation. These hypothesis-generating findings can guide approaches to improve referral patterns for this important aspect of supportive care.

Radiation Oncologists' Role in End-of-Life Care: A Perspective From Medical Oncologists

PURPOSE

Multidisciplinary communication and collaboration are key to planning and delivering end-of-life care for patients with advanced and metastatic cancer. We sought to characterize medical oncologists' perspectives on the role of radiation oncologists in end-of-life care.

MATERIALS AND METHODS

A sample of US medical oncologists was recruited using snowball sampling methods. Audio recordings of 4 professionally moderated focus groups were transcribed. Investigators from diverse backgrounds (medical oncology, radiation oncology, critical care medicine, palliative care, and public health) independently reviewed each transcript. Qualitative content analysis was used to create consensus codes that were applied to subsequent focus group transcripts in an iterative process.

RESULTS

Medical oncologists expressed complex views regarding the role of radiation oncologists in end-of-life care. Identified themes included the limited role of radiation oncologists, territorial concerns, capability, and desire of radiation oncologists in this realm, and the need for communication between providers. Radiation oncologists were compared with surgeons, whose interaction with patients ceased after their service had been performed. In this regard, control of palliative care referral or end-of-life care discussions was thought to be in the territory of medical oncologists who had longitudinal relationships with patients from diagnosis. Medical oncologists were concerned about the capability of radiation oncologists to accurately prognosticate, and stated radiation oncologists lacked knowledge of subsequent lines of systemic therapy available to patients. Radiation oncologists' fear of upsetting medical oncologists was thought to be justified if they engaged in end-of-life care planning without direct permission from the referring medical oncologist.

CONCLUSIONS

Participation of radiation oncologists in end-of-life care planning was viewed with skepticism by medical oncologists. Radiation oncologists should focus on increasing open communication and teamwork with medical oncologists and demonstrate their ability to prognosticate and counsel patients regarding end-of-life care decisions.

Palliative beam radiotherapy offered real-world survival benefit to metastatic rectal cancer: A large US population-based and propensity score-matched study

Purpose: Radiotherapy (RT) has been reported to effectively palliate many symptoms of patients with metastatic rectal cancer (mRC). The objective of this study was to evaluate the survival benefit of RT in mRC. Methods: A retrospective population-based cohort study was performed using the Surveillance, Epidemiology, and End Results Program (SEER) database. Patient baseline demographic characteristics between the RT and no-RT groups were compared using Pearson chi-square tests. The outcome of interest was cause-specific survival (CSS). Propensity score (PS) matching and Cox proportional hazards regression analyses were performed to evaluate the prognostic power of variables on CSS. Results: A total of 8851 patients with mRC were identified in the SEER database. Multivariable Cox regression analysis showed that RT was a protective factor in mRC (hazard ratio [HR]= 0.702, 95% confidence interval [CI]=0.665-0.741, p<0.001). In subgroup analysis, multivariate Cox analysis demonstrated that patients of both surgery and no-surgery subgroups treated with RT had better CSS than those not treated with RT (HR=0.654, 95%CI=0.607-0.704, p<0.001 for the surgery group; HR=0.779, 95%CI=0.717-0.847, p<0.001 for the no-surgery group), PS matching resulted in 4170 mRC patients and RT group presented significantly improved survival benefit than no-RT group (22.0 vs. 13.5%, P <0.001). In surgery subgroup after PS matching, in especial, RT group showed more evidently improved survival benefit than no-RT group (30.3 vs. 18.0%, p <0.001). Conclusion: Using the SEER database, we definitely demonstrated that RT was associated with a significant survival advantage beyond the relief of a variety of pelvic symptoms in the setting of mRC. This study strongly supports the use of RT in selected patients with mRC, especially in patients who have undergone surgery. More studies need to be conducted to accurately define the role of RT in mRC.

Palliative radiation and fractionation in medicare patients with incurable non-small cell lung cancer

PURPOSE

Palliative radiation therapy (RT) can improve quality of life but also incurs time and financial costs. The aim of this study was to evaluate factors associated with use and intensity of palliative RT for incurable non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

This was a retrospective analysis of Medicare's Surveillance, Epidemiology and End Results data. We identified patients who were diagnosed with incurable (American Joint Committee on Cancer 6th edition stage IIIB with malignant effusion or stage IV) NSCLC between 2004 and 2011. Univariable and multivariable logistic regressions were used to identify factors associated with the receipt of palliative RT and the use of >10 fractions during the first course of radiation. Among patients who were treated with radiation, freestanding versus hospital-based center information was collected on the basis of the location of the RT delivery claim.

RESULTS

Among 55,258 patients with incurable NSCLC, 38% (21,053 patients) received palliative RT during the first year after diagnosis. Among patients who received RT, 56% (11,717 patients) received >10 fractions. On multivariable analysis, factors associated with greater RT use included younger age group (overall P < .01), lower modified Charlson comorbidity score (overall P < .01), female sex (odds ratio [OR]: 1.1; P < .01), marital status (OR: 1.1; P < .01), and chemotherapy use (OR: 3.6; P < .01). Predictors for >10 fractions were chemotherapy use (OR: 1.7; P < .01) and treatment at a freestanding versus hospital-based facility (58% vs 43%; OR: 1.7; P < .01).

CONCLUSIONS

More than a third of patients diagnosed with incurable lung cancer receive palliative RT and 56% received >10 fractions. The use of RT varied by region and patient characteristics, and patients treated at freestanding RT centers were more likely to receive >10 fractions. Further research into factors that influence treatment decisions including potential financial incentives may contribute to the high value and strategic utilization of palliative RT.

Top Ten Tips Palliative Care Clinicians Should Know When Caring for Patients with Endometrial Cancer

Endometrial cancer incidence has been increasing over the last two decades, likely due to the obesity epidemic. The majority of these cancers are confined to the uterus at diagnosis and can be cured with surgery. Overall, five-year disease-specific survival is about 80%, but some patients have locally advanced or metastatic disease that is not amenable to control with radiation and/or chemotherapy. Disease-related symptoms are most common in this subset of patients with endometrial cancer, although women with early-stage disease may also experience side effects related to surgical menopause or adjuvant treatment. In recent years, professional societies have been increasingly vocal about the importance of incorporating palliative care early in a patient's disease course. As these calls increase, palliative care clinicians will likely increasingly comanage patients with advanced or recurrent endometrial cancer. We brought together a team of gynecologic oncology and palliative care experts to assemble practical tips for the care of women with endometrial cancer. In this article, we use a "Top 10" format to highlight issues that may help palliative care physicians understand a patient's prognosis, address common misconceptions about endometrial cancer, and improve the quality of shared decision making and goals of care discussions.

Top 10 Tips Palliative Care Clinicians Should Know About Radiation Oncology

As palliative care (PC) moves upstream in the course of advanced illness, it is critical that PC providers have a broad understanding of curative and palliative treatments for serious diseases. Possessing a working knowledge of radiation therapy (RT), one of the three pillars of cancer care, is crucial to PC providers given RT's role in both the curative and palliative settings. This article provides PC providers with a primer on the vocabulary of RT; the team of people involved in the planning of RT; and common indications, benefits, and side effects of treatment.

Patterns and Yearly Time Trends in the Use of Radiation Therapy During the Last 30 Days of Life Among Patients With Metastatic Rectal Cancer in the United States From 2004 to 2012

PURPOSE

Although radiation therapy (RT) can provide palliative benefits for patients with metastatic rectal cancer, its role at the end of life remains unclear. The objective of this study was to assess sociodemographic and clinical factors associated with the use of RT during the last 30 days of life and to evaluate yearly time trends in RT utilization among stage IV patients with rectal cancer.

METHODS

The 2004 to 2012 National Cancer DataBase was queried for patients with metastatic rectal cancer who had a documented death during follow-up. A Bayesian multilevel logistic regression model was used to characterize predictive factors and yearly time trends associated with RT use in the last 30 days of life.

RESULTS

Among 10 431 patients who met inclusion criteria, 345 (3%) received RT during the last 30 days of life. Factors independently associated with RT use included older age, female sex, African American race, nonprivate insurance, higher comorbidity burden, and worse grade. The odds of RT use at the end of life decreased by 28% between 2007 and 2009 (odds ratio [OR] = 0.72, 95% Credible Interval (CI) = 0.58-0.93), but then increased by 16% from 2010 to 2012 (OR = 1.16, 95% CI = 1.13-1.33), relative to 2004 to 2006.

CONCLUSION

Radiation therapy use for patients with metastatic rectal cancer is beneficial, and efforts to optimize its appropriate use are important. Several factors associated with RT use during the last 30 days of life included disparities in sociodemographic and clinical subgroups. Research is needed to understand the underlying causes of these inequalities and the role of predictive models in clinical decision-making.

Effectiveness of radiotherapy for metastatic spinal cord compression in patients with short life expectancy

AIM

To analyze the effect of radiotherapy (RT) in patients with metastatic spinal cord compression (MSCC) and poor prognosis in our center.

BACKGROUND

RT is an effective treatment for MSCC.

MATERIALS AND METHODS

Prospective evaluation on patients with MSCC and limited survival (according to Rades' scale), and treated with single-dose 8 Gy RT (February 2013-August 2014). Pain, ambulatory status and sphincter control were recorded. Pain relief was evaluated following the International Bone Metastases Consensus Working Party Guidelines. Ambulatory status was evaluated with Frankel's scale. Spinal fracture and instability were recorded. Health aspects were evaluated via a short survey and measuring the time spent on RT.

RESULTS

35 patients were included. 51% had unfavorable histologies; 60% bone fracture and 17% spinal instability. Median Karnofsky score was 60; 100% were on high doses of opioids. Median survival was 1.5 months. 49% had a partial pain response at 2 weeks post-radiation, and 47% at one month. Significant reductions in pain intensity were present at 2 weeks (Visual analog scale, VAS score, from 8 ± 1.5 to 5 ± 1.9). Negligible effects were observed on motor and bladder function, along with side effects. KPS score was maintained during follow-up. 80% of patients spent ≤5% of their remaining lifetime on RT. A survey comparison between clinical judgment and the results according to treatment decision consider that these patients merit treatment evaluation.

CONCLUSIONS

A moderate pain response tailored to life expectancy can be obtained in patients treated with radiation. 8-Gy single-dose is an option for patients with limited survival.

Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort

BACKGROUND

Palliative radiotherapy (PRT) can significantly improve quality of life for patients dying of cancer with bone metastases. However, an aggressive cancer treatment near end of life is an indicator of poor-quality care. But the optimal rate of overall palliative RT use near the end of life is still unknown. We sought to determine the patterns of palliative radiation therapy (RT) utilization in patients with bone metastases towards their end of life in a population-based, publicly funded health care system.

METHODS

All consecutive patients with bone metastases treated with RT between 2007 and 2011 were identified in a provincial Canadian cancer registry database. Patients were categorized as receiving RT in the last 2 weeks, 2-4 weeks, or >4 weeks before their death. Associations between RT fractionation utilization by these categories, and patient and provider characteristics were assessed through logistic regression.

RESULTS

Of the 16,898 courses 1734 (10.3) and 709 (4.2%) were prescribed to patients in the last 2-4 weeks and <2 weeks of their life, respectively. Primary lung (8%) and gastrointestinal (6.9%) cancers received palliative RT more commonly in the last 2 weeks of life (OR 3.72 [2.86-4.84] & 3.33 [2.42-4.58] respectively, p <0.001). Among the 709 patients who received RT in the last 2 weeks of life, 350 (49), 167 (24), and 127 (18%) were for spine, pelvis, and extremity metastases, respectively. RT was prescribed most frequently to spine (5%) and extremity (4%) metastases p <0.001 in the last two weeks of life, though only varied between 1% (sternum) and 5% (spine) by site of metastases. Single fraction RT was prescribed more commonly in the last 2 weeks of life (64.2%), compared to individuals who received RT 2-4 weeks (54.5), and >4 weeks (47.9%) before death (p <0.001).

CONCLUSIONS

This population-based analysis found that only 4% of patients with bone metastases received radiation therapy during the last 2 weeks of their life in our population-based, publicly funded program, though it was significantly higher in patients with lung cancer and those with metastases to the spine or extremity. Appropriately, use of multiple fractions palliative RT was less common in patients closer to death.

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.

Palliative radiotherapy at the end of life: a critical review

When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life.

Role of radiation therapy in palliative care of the patient with cancer

Radiotherapy is a successful, time-efficient, well-tolerated, and cost-effective intervention that is crucial for the appropriate delivery of palliative oncology care. The distinction between curative and palliative goals is blurred in many patients with cancer, requiring that treatments be chosen on the basis of factors related to the patient (ie, poor performance status, advanced age, significant weight loss, severe comorbid disease), the cancer (ie, metastatic disease, aggressive histology), or the treatment (ie, poor response to systemic therapy, previous radiotherapy). Goals may include symptom relief at the site of primary tumor or from metastatic lesions. Attention to a patient's discomfort and transportation limitations requires hypofractionated courses, when feasible. Innovative approaches include rapid response palliative care clinics as well as the formation of palliative radiotherapy specialty services in academic centers. Guidelines are providing better definitions of appropriate palliative radiotherapy interventions, and bone metastases fractionation has become the first radiotherapy quality measure accepted by the National Quality Forum. Further advances in the palliative radiation oncology subspecialty will require integration of education and training between the radiotherapy and palliative care specialties.

Radiation therapy in the last month of life

AIM

We sought to survey a large, multi-center patient sample to better characterize/quantify RT utilization at the end of life.

BACKGROUND

Few objective data exist for radiation therapy (RT) delivery at end of life (EOL).

MATERIALS AND METHODS

Data were retrieved for all patients receiving RT in calendar year 2010 in the Department of Radiation Oncology at Indiana University (IU) and Howard University (HU) hospitals. Specific attention was made of the group of patients receiving RT in the last 30 days of life.

RESULTS

A total of 852 patients received all or part of their RT during 2010 (HU: 139, IU: 713). At time of analysis in early 2012, 179 patients had died (21%). Fifty-four patients (6.3% of total; 30% of expired patients) died within 30 days of receiving their last treatment. Twenty patients (2.3% of total; 11.2% of expired patients) received RT within their last week of life. For both sites, the median time until death from completion of therapy was 12.5 days (range 2-30 days).

CONCLUSIONS

Radiation in the last month of life is likely to provide minimal palliation or survival benefit. This, coupled with the financial implications, time investment, and physical costs, suggests that physicians and patients should more strongly consider hospice, and minimize duration of palliative RT courses as far as possible. As with chemotherapy, RT utilization at EOL should be considered for collection as an overuse metric.

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.

Does overall treatment time impact on survival after whole-brain radiotherapy for brain metastases?

PURPOSE To evaluate whether reduced overall treatment time (OTT), i.e., administration of more than 5 fractions per week, or uncompensated treatment interruption resulting in increased OTT influences survival of patients treated with whole-brain radiotherapy (WBRT) for brain metastases. METHODS Retrospective multi-institutional intention-to-treat study including 233 patients treated with primary WBRT (prescribed dose 10 fractions of 3 Gy; no previous SRS or surgery) administered over 10-38 days. Four groups were studied: OTT 10-11 vs. 12 days, 13-15 or >15 days. RESULTS Fourteen patients (6%) failed to complete WBRT and received 3-9 fractions (median 7). Their median survival was 0.5 months as compared to 3 months in patients who completed WBRT. No significant impact of OTT on survival was found. Median survival was 1.5, 2.9, 3.0 and 3.1 months in the four groups mentioned above. CONCLUSIONS Compensation for unintended treatment interruption is generally recommended but might not always be feasible. Depending on histological tumour type or expected repopulation, prognostic factors and neurological status, it might be acceptable to complete an interrupted course of WBRT without compensation in selected patients. While survival might be largely independent from OTT, it should also be evaluated whether this parameter has any impact on quality of life and duration of palliation.