Palliative radiotherapy near the end of life

A Practice Model for Palliative Radiotherapy

Despite well-recognized challenges in implementing palliative radiation therapy (PRT), progress remains slow, and conventional approaches have yielded limited success. A transformative strategy is required to overcome systemic barriers and establish a sustainable PRT infrastructure. This proposal presents a novel model to improve accessibility, affordability, and integration into palliative care by addressing key obstacles in training, regulation, facility development, and treatment protocols. A specialized certification track within radiation oncology residency programs is proposed, enabling palliative care physicians to obtain limited PRT licenses under the supervision of fully licensed radiation oncologists. Regulatory adjustments should facilitate this framework, ensuring compliance while expanding the PRT workforce. Dedicated PRT facilities-affiliated with comprehensive radiation therapy centers (CRTCs) and integrated into hospice settings-will enhance accessibility by reducing logistical and financial burdens. These facilities will utilize cost-effective infrastructure, including refurbished linear accelerators, modular construction, and remote physics and dosimetry support, ensuring operational costs remain significantly lower than those of conventional radiotherapy centers. Optimizing PRT delivery requires shifting clinical strategies toward single-fraction treatment as the primary approach, followed by hypofractionation treatment when necessary. Systematic studies with a PRT-oriented mindset should establish PRT-specific treatment recommendations and recommendations, moving away from conventional radiation therapy protocols. By addressing key barriers in education, regulation, infrastructure, and clinical strategy, this model offers a path toward sustainable PRT implementation. While requiring initial investment and regulatory adjustments, it has the potential to improve end-of-life care for terminally ill cancer patients, ensuring greater dignity and comfort while establishing a robust foundation for future reimbursement models.

Palliative Radiotherapy Near the End of Life: An Analysis of Factors Influencing the Administration of Radiotherapy in Advanced Tumor Disease

PURPOSE

Palliative radiotherapy (PRT) toward the end of life (EOL) in advanced tumor disease is contentious. Although EOL RT can alleviate cancer-related symptoms, relief typically occurs weeks to months after treatment, potentially compromising the quality of life of patients during the final stages. This study aims to assess factors influencing the decision-making process regarding EOL RT.

MATERIALS AND METHODS

This retrospective study of a real-world cohort included 684 consecutive patients with a diagnosis of a solid tumor who died between 2017 and 2021. In these patients, factors potentially influencing the administration of EOL RT were analyzed.

RESULTS

Of the 684 patients, 164 received PRT, with 60 (36.6%) receiving EOL RT within the last 30 days of life. The median time from the last RT session to death was 55 days. Significant factors influencing EOL RT administration were age ≤65 years (odds ratio [OR], 1.75 [95% CI, 1.02 to 3.01]), Union for International Cancer Control stage IV (OR, 2.77 [95% CI, 1.41 to 5.46]), lung cancer (OR, 2.16 [95% CI, 1.00 to 4.68]), palliative care referral (OR, 1.80 [95% CI, 0.98 to 3.30]), systemic anticancer treatment ≤30 days before death (OR, 1.87 [95% CI, 1.05 to 3.33]), and Eastern Cooperative Oncology Group performance status ≥2 (OR, 3.73 [95% CI, 1.88 to 7.40]). Furthermore, RT near the EOL was more likely administered at multiple sites (OR, 2.08 [95% CI, 1.00 to 4.29]) and with ≤5 fractions (OR, 2.37 [95% CI, 1.23 to 4.57]), while being associated with lower response rates (OR, 0.43 [95% CI, 0.21 to 0.86]) and increased therapy discontinuation (OR, 4.40 [95% CI, 1.45 to 13.37]).

CONCLUSION

These findings highlight varying RT patterns influenced by specific factors, demonstrating the complexity of EOL treatment decisions in advanced cancer care. Identifying key factors for personalized, patient-centered EOL RT decisions warrants further investigation.

Implications of primary tumor site and fraction size on outcomes of palliative radiation for osseous metastases

Purpose

This study reviewed palliative radiation therapy (RT) practices and outcomes and compared the percentage of remaining life spent receiving RT (PRLSRT) in patients treated for osseous metastases.

Methods

A retrospective analysis was conducted using the National Cancer Database (2010-2016) to evaluate metastatic patients who received palliative bone RT. Common palliative RT schemes were analyzed to determine treatment patterns and outcomes. Palliative outcomes, including median PRLSRT, RT completion, and mortality rates, were calculated. Binary logistic regression was performed to identify factors affecting RT completion, and a scoring system was developed to identify patients at risk for poor palliative outcomes.

Results

A total of 50,929 patients were included, with the majority diagnosed with NSCLC (45.2%), breast cancer (15.1%), or prostate cancer (10.8%). The median overall survival after palliative RT was 5.74 months. Patients receiving lower doses per fraction (2.5 Gy/Fx) tended to be younger, healthier, and yet experienced worse palliative outcomes. Binary logistic regression identified age, race, income quartile, and Gy/Fx as significant factors affecting RT completion. Median PRLSRTs were as follows: 14.95% for GI NOS, 9.89% for upper GI, 9.46% for NSCLC, 8.67% for skin, 7.06% for SCLC, 6.10% for lower GI, 5.59% for GYN, 5.44% for GU, 5.35% for HNC, 2.05% for endocrine, 2.03% for prostate cancer, and 1.82% for breast cancer. Patients receiving 2.5 and 3 Gy/Fx were less likely to complete RT compared to those receiving 4 Gy/Fx (OR, 1.429 and 3.780, respectively; p < 0.001). Age, comorbidities, primary tumor, target location, and metastatic burden were associated with PRLSRT ≥ 25%.

Conclusion

Dose regimens and patient selection influence palliative bone RT outcomes. Both factors should be carefully considered to minimize the burden of care and maximize treatment benefits.

Outcomes of patients receiving urgent palliative radiotherapy for advanced lung cancer: an observational study

BACKGROUND

There is considerable variability in the management of patients with advanced lung cancer referred for palliative radiotherapy owing to uncertainties in prognosis and the benefit of treatment. This study presents the outcomes of patients seen in the Fast Track Lung Clinic, an urgent access palliative radiotherapy clinic, and aims to identify factors associated with treatment response and survival.

METHODS

Consecutive patients with advanced lung cancer seen in the Fast Track Lung Clinic between January 2014 and July 2020 were included. Patients who underwent radiotherapy were contacted beginning 30 days after radiotherapy to evaluate treatment response. Cluster bootstraps were used to compute confidence intervals for treatment response rate. Prognostic factors for treatment response and overall survival were identified using multivariable generalized estimating equations and Cox regression models, respectively.

RESULTS

A total of 558 patients were included, of whom 459 (82.3%) consented to palliative radiotherapy for 1053 indications. The overall treatment response rate was 70.0% (95% CI, 65.8-74.2) for indications with follow-up (70.8%). Higher response rates were observed in patients with better ECOG performance status (OR per point, 0.71; 95% CI, 0.55-0.93; P = 0.01 ) and EGFR-mutant non-small cell lung cancer (OR vs wild-type, 2.46; 95% CI, 1.35-4.51; P = 0.003 ), whereas patients treated for neurological symptoms had lower response rates (OR, 0.27; 95% CI, 0.16-0.45; P < 0.001 ). There was no difference in response rate between patients who died within 30 days of starting radiotherapy and those who survived longer (OR, 0.83; 95% CI, 0.42-1.67; P = 0.61 ). Age; ECOG performance status; smoking history; pathology; EGFR or ALK mutation status; and the presence of liver, adrenal, or brain metastases were associated with overall survival.

CONCLUSIONS

Palliative radiotherapy was effective for patients with advanced lung cancer, although response rates varied by patient characteristics and treatment indication. This study identified prognostic factors for radiotherapy response and overall survival that can inform treatment decisions in this population.

Stereotactic radiotherapy for patients with bone metastases: a selected group with low rate of radiation treatment during the last month of life?

BACKGROUND

Complex high-precision radiotherapy, such as stereotactic body radiotherapy (SBRT), should only be offered to patients with sufficiently long survival. In the context of bone metastases radiotherapy, low rates of treatment close to the end of life, e.g. last 30 days (RT30), may serve as a quality of care indicator. While traditional, pain-relieving short-course regimens have been studied comprehensively, real-world SBRT results are still limited.

METHODS

Retrospective analysis (2010-2023, n = 1117 episodes) of patients with bone metastases treated with traditional single-fraction (8 Gy × 1) or multi-fraction regimens (often 4 Gy × 5 or 3 Gy × 10) compared to stereotactic single-fraction (12-16 Gy × 1) or multi-fraction regimens.

RESULTS

Except for gender, almost all baseline variables were uneven distributed. Failure to complete fractionated radiotherapy was uncommon in the stereotactic (4%) and non-stereotactic group (3%), p = 1.0. With regard to RT30, relevant differences emerged (19% for 8-Gy single-fraction versus 0% for stereotactic single-fraction, p = 0.01). The corresponding figures were 11% for multi-fraction non-stereotactic and 2% for multi-fraction stereotactic, p = 0.08. Median overall survival was shortest after 8-Gy single-fraction irradiation (4.2 months) and longest after stereotactic multi-fraction treatment (13.9 months). Neither stereotactic radiotherapy nor multi-fraction treatment improved survival in multivariate Cox regression analysis. Factors significantly associated with longer survival included better performance status, lower LabBM score (5 standard blood test results), stable disease outside of irradiated area(s), metachronous distant metastases, longer time interval from metastatic disease to bone irradiation, and outpatient status.

CONCLUSION

The implementation of SBRT for selected patients has resulted in low rates of non-completion and RT30. Optimal selection criteria remain to be determined, but in current clinical practice we exclude patients with poor performance status, unfavorable blood test results (high LabBM score) and progressive disease sites not amenable to SBRT. Established, guideline-endorsed short-course regimens, especially 8-Gy single-fraction treatment, continue to represent an important palliative approach.

Utilization of medical interventions in hospitalized Mexican adults with cancer at the end of life in a referral hospital: The importance of early palliative care

OBJECTIVES

To investigate the impact of early vs. late palliative care (PC) on the frequency of admissions to acute hospital settings and the utilization of end-of-life (EoL) interventions in cancer decedents.

METHODS

In this single-center, cross-sectional study, we examined the frequency of intensive care unit (ICU) and emergency department (ED) admissions among adult cancer decedents between 2018 and 2022 in a referral hospital in México. Additionally, we assessed EoL medical interventions, categorizing patients into 3 groups: those who received early PC (EPC), late PC (LPC), and those who did not receive PC (NPC).

RESULTS

We analyzed data from 1762 patients, averaging 56 ± 16.3 years old, with a predominant representation of women (56.8%). PC was administered to 45.2% of patients, but EPC was limited to only 12.3%. The median time from the initiation of PC to death was 5 days (interquartile range: 2.0-31.5). Hematological malignancies were the most prevalent, affecting 21.5% of patients. EPC recipients demonstrated notable reductions in ICU and ED admissions, as well as diminished utilization of chemotherapy, radiotherapy (RT), antibiotics, blood transfusions, and surgery when compared to both LPC and NPC groups. EPC also exhibited fewer medical interventions in the last 14 days of life, except for RT.

SIGNIFICANCE OF RESULTS

The findings of this study indicate that a significant proportion of EoL cancer patients receive PC; however, few receive EPC, emphasizing the need to improve accessibility to these services. Moreover, the results underscore the importance of thoughtful deliberation regarding the application of EoL medical interventions in cancer patients.

Diagnostic CT-Enabled Planning (DART): Results of a Randomized Trial in Palliative Radiation Therapy

PURPOSE

Using diagnostic computed tomography (dCT) scans instead of CT simulation (CTsim) scans can increase departmental efficiency and reduce patient burden. The goal of the DART trial was to assess the efficacy and acceptability of dCT-based planning workflows with a focus on patient experiences, plan deliverability and adequacy of target coverage, and workflows.

METHODS AND MATERIALS

Patients undergoing same-day CTsim and treatment for palliative radiation therapy to thoracic, abdominopelvic, or proximal limb targets with a recent dCT (within 28 days) in a reproducible position were eligible. After stratifying by target type (bone or soft tissue vs. visceral), participants were randomized (1:2 ratio) between CTsim-based (CTsim arm) vs. dCT-based planning (dCT arm). The primary endpoint was time in center (TIC), defined as total time spent in the cancer center on first day of treatment, from first radiation department appointment to first fraction completion. Secondary endpoints included plan deliverability, adequacy of target coverage, and stakeholder acceptability.

RESULTS

Thirty-three patients (42 treatment sites) were enrolled between June 2022 and April 2023. The median age was 72 (interquartile range [IQR]: 67-78), 73% were male, and the most common primary cancers were lung (33%), prostate (24%), and breast (12%). The most common dose and fractionations were 8 Gy in 1 and 20 Gy in 5 fractions (50% and 43% of plans, respectively). TIC was 4.7 ± 1.1 hours (mean ± SD) in the CTsim arm vs. 0.41 ± 0.14 hours in the dCT arm (P < .001). All dCT plans were deliverable. All plans in both arms were rated as "acceptable" (80% CTsim; 81% dCT) or "acceptable with minor deviation" (20% CTsim; 19% dCT). Patient perception of acceptability was similar in both arms with the exception of time burden, which was rated as "acceptable" by 50% in the CTsim arm vs. 90% in the dCT arm (P = .025).

CONCLUSION

dCT-based radiation planning substantially reduced TIC without detriment in plan deliverability or quality and had a tangible impact on patient experience with reduced patient-reported time burden.

Palliative Radiotherapy in Non-small Cell Lung Cancer: Patterns of Use and Predictors of 30-Day Mortality in End-of-Life Care

Introduction Lung cancer is the leading cause of cancer-related deaths worldwide, with non-small cell lung cancer (NSCLC) being the most common type. More than half of patients require radiotherapy throughout their treatment. Palliative radiotherapy (PRT) is an important tool for symptom control and quality of life improvement in advanced NSCLC patients. However, the benefits of PRT must be balanced against possible disadvantages, especially in end-of-life (EOL) care. This study aims to describe the profile of PRT-treated deceased NSCLC patients, quantify the proportion of PRT recipients in the last 30 days of life and identify short-term survival prognostic factors in this group. Materials and methods This retrospective analysis was performed at two radiotherapy facilities within the Kent Oncology Centre, UK, for two years, running from January 1, 2022, to January 1, 2024. Data were collected from 857 deceased NSCLC patients who received PRT. Demographics, cancer diagnosis, histology, tumour, node, metastasis (TNM) staging, radiotherapy details, recent treatments, performance status (PS) and comorbidities were analysed. Patients have been stratified as long-term survivors (more than 30 days after PRT initiation, LTS group) along with short-term survivors (STS) (died within 30 days, STS group). Descriptive statistics, chi-squared tests, t-tests and multivariable logistic regression have been used in the data analysis. Results Out of 857 patients, 148 (17.3%) died within 30 days of PRT initiation. PS was considerably worse (p = 0.027), Adult Comorbidity Evaluation 27 (ACE-27) scores were higher (p = 0.018), and metastatic disease was more prevalent (60.1% vs. 47.5%, p = 0.02) in STS group patients. Fewer patients in the STS group completed their treatment compared to the LTS group (63.5% vs. 82.8%, p < 0.001). The STS group also received lower mean radiation dose (17.7 Gy vs. 19.6 Gy, p = 0.022) and fewer fractions (4.4 vs. 5.2, p = 0.019). The most common RT regimen in both cohorts was 20 Gy in five fractions, used in 55.4% of STS and 49.8% of LTS patients, with no significant difference in single fraction RT use between groups (33.1% in STS vs. 36.8% in LTS, p = 0.401). Multivariate logistic regression identified significant predictors of 30-day mortality: poorer PS (adjusted OR: 1.981, 95% CI: 1.33-3.12, p = 0.001), metastatic disease (adjusted OR: 2.02, 95% CI: 1.246-3.571, p = 0.002), incomplete PRT (adjusted OR: 0.337, 95% CI: 0.21-0.514, p < 0.001) and no recent chemotherapy (adjusted OR: 0.542, 95% CI: 0.342-0.941, p = 0.044). Conclusion This study demonstrated that compared with previous reports, a higher proportion of NSCLC patients who received PRT died within 30 days of treatment initiation, and low treatment adherence rates highlight challenges in EOL settings. Identification of poor PS and metastatic disease as predictors of short-term mortality would help inform PRT decision-making. The underutilisation of single-fraction radiotherapy and the link between recent chemotherapy and lower 30-day mortality warrant further study. These results highlight the need for better prognostic tools and more selective use of PRT, including increased consideration of single-fraction radiotherapy, in NSCLC patients approaching end of life and emphasise the importance of balancing benefit against treatment burden in this vulnerable population.

Palliative radiotherapy: New prognostic factors for patients with bone metastasis

PURPOSE

Many cancer patients develop bone metastases, however the prognosis of overall survival differs. To provide an optimal treatment for these patients, especially towards the end of life, a reliable prediction of survival is needed. The goal of this study was to find new clinical factors in relation to overall survival.

MATERIALS AND METHODS

Prospectively 22 clinical factors were collected from 734 patients. The Kaplan-Meier and Cox regression models were used.

RESULTS

Most patients were diagnosed with lung cancer (29%), followed by prostate (19.8%) and breast cancer (14.7%). Median overall survival was 6.4months. Fourteen clinical factors showed significance in the univariate analyses. In the multivariate analyses 6 factors were found to be significant for the overall survival: Karnofsky performance status, primary tumor, gender, total organs affected, morphine use and systemic treatment options after radiotherapy.

CONCLUSION

Morphine use and systemic treatment options after radiotherapy, Karnofsky performance status, primary tumor, gender and total organs affected are strong prediction factors on overall survival after palliative radiotherapy in patients with bone metastasis. These factors are easily applicable in the clinic.

Palliative radiotherapy and the introduction of a Rapid Access Palliative Clinic in a national radiation oncology network

BACKGROUND

Palliative radiotherapy (PRT) is commonly used to treat symptoms of advanced cancer. PRT has been associated with elevated 30-day mortality (30DM). A Rapid Access Palliative Clinic (RAPC) can streamline the treatment process for patients receiving treatment.

AIMS

We reviewed the PRT practices in a radiation oncology network in Ireland, and the implementation of a RAPC. Patient outcomes were assessed to inform future treatment decisions.

METHODS

A retrospective review of all patients who received PRT over 6 months in 2018 in St. Luke's Radiation Oncology Network (SLRON) was undertaken. We assessed 30DM rates, demographics and referral to specialist palliative care (SPC) services. Subsequently, a retrospective analysis was conducted of a RAPC which ran for 6 months from 2019 to 2020. We assessed treatment data and mortality.

RESULTS

Over 6 months, 645 patients commenced PRT in the SLRON. The 30DM for this cohort was 15.8% (n = 102), with most patients having lung primaries. Of the 30DM cohort, only 55% (n = 56) were referred to SPC services and only 26.4% (n = 27) had performance status recorded. Over 6 months, 40 patients attended 28 RAPCs. Of these, 88% (n = 35) received PRT. Single fraction therapy was utilised in 60% and 48% of patients underwent CT simulation and treatment on the same day. Ultimately, 75% of patients received SPC referral.

CONCLUSIONS

Referral rates to SPC services and documentation of performance status were low in our 30DM retrospective review cohort. The RAPC facilitated quick treatment turnaround, fewer hospital visits and referral to SPC services.

Variation in Access to Palliative Radiotherapy in Prostate Cancer: A Population-Based Study in Canada

BACKGROUND

As a result of improvements in cancer therapies, patients with metastatic malignancies are living longer, and the role of palliative radiotherapy has become increasingly recognized. However, access to adequate palliative radiotherapy may continue to be a challenge, as is evident from the high proportion of patients dying of prostate cancer who never receive palliative radiotherapy. The main objective of this investigation is to identify and describe the factors associated with the receipt of palliative radiation treatment in a decedent cohort of prostate cancer patients in Ontario.

METHODOLOGY

 Population-based administrative databases from Ontario, Canada, were used to identify prostate cancer decedents, 65 years or older who received androgen deprivation therapy between January 1, 2013, and December 31, 2018. Baseline and treatment characteristics were analyzed using univariate and multivariate logistic regression models for association with receipt of radiotherapy in a two-year observation period before death.

RESULTS

We identified 3,788 prostate cancer decedents between 2013 and 2018; among these, 49.9% received radiotherapy in the two years preceding death. There were statistically significant positive associations between receipt of radiotherapy and younger age at diagnosis (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.3); higher stage at diagnosis (OR 1.3, 95% CI 1.1-1.7); receipt of care at a regional cancer center (OR 1.8, 95% CI 1.3-2.4); and involvement of radiation oncologists (OR 155.1, 95% CI 83.3-288.7) or medical oncologists (OR 1.4, 95% CI 1.1-1.8). However, there were no associations between receipt of radiotherapy and income, distance to the nearest cancer center, involvement of urologists in cancer care, healthcare administrative region, home-care involvement, or number of hospitalizations in the observation period.

CONCLUSIONS

We found the utilization of palliative radiotherapy for prostate cancer patients in Ontario varies depending on age, stage at diagnosis, number of comorbidities, registration at regional cancer centers, and involvement of oncologists. There were no differences detected based on income or distance from a cancer center. The findings of this study represent an important opportunity to facilitate better access to palliative radiotherapy and referrals to multidisciplinary regional cancer centers, to improve the quality of life of this patient population.

The use of electronic Patient Reported Outcomes in follow-up after palliative radiotherapy: A survey study in Belgium

Objective

Electronic Patient-Reported Outcome Measures (ePROMs) could be used to monitor patients' symptoms after treatment. However, ePROM implementation in clinical practice has been challenging, especially in (palliative) radiation oncology. The aim of this study was to explore the opinions of healthcare providers (HCP) active in radiation oncology in Belgium on the use of ePROMs for symptom follow-up after palliative radiotherapy.

Methods

An anonymous online survey was conducted with different HCP in radiation oncology in Belgium. Participants were recruited through several professional organizations with approximately 390 members actively working in the field of radiation oncology. The survey used was a self-developed questionnaire, based on existing literature on implementation of (e)PROMs in cancer care, our previous research on this topic as well as our personal experience in the field of oncology and palliative care.

Results

Of the 128 respondents, 26% had experience with ePROMs in clinical practice. Eighty-four percent considered ePROMs beneficial for patients' health and symptom knowledge, symptom self-management and active participation in care. ePROMs could help HCP to focus on detection of relevant symptoms and improve their management. Almost 75% were willing to implement and use ePROMs. Assigning ePROM introduction and follow-up to a dedicated person, such as a nurse navigator, was suggested to promote ePROM implementation and use in clinical practice.

Conclusion

Despite limited experience with ePROMs in clinical care for palliative radiotherapy patients, the majority of respondents is willing to implement and use ePROMs for this particular patient population.

Innovation

This is one of the first studies specifically focusing on experiences and opinions of HCP in radiation oncology on the use of ePROMs for symptom follow-up in palliative radiotherapy. HCP should be actively involved in implementation of ePROMs after palliative radiotherapy, to translate their vision of their ideals in practice.

Radiation Therapy in the Last Month of Life: Association With Aggressive Care at the End of Life

CONTEXT

Half of the patients with cancer who undergo radiation therapy do so with palliative intent.

OBJECTIVES

To determine the proportion of undergoing radiation in the last month of life, patient characteristics, cancer course, the type and duration of radiation, whether palliative care was involved, and the of radiation with aggressive cancer care metrics.

METHODS

One thousand seven hundred twenty-seven patients who died of cancer between January 1, 2018, and December 31, 2019, were included. Demographics, cancer stage, palliative care referral, advance directives, use of home health care, radiation timing, and survival were collected. Type of radiation, course, and intent were reviewed. Chi-square analysis was utilized for categorical variables, and Kruskal-Wallis tests for continuous variables. A stepwise selection was used to build a Cox proportional hazard model.

RESULTS

Two hundred thirty-three patients underwent radiation in the last month of life. Younger patients underwent radiation 67.3 years (SD 11.52) versus 69.2 years (SD 11.96). 42.6% had radiation within two weeks of death. The average fraction number was 5.5. Individuals undergoing radiation were more likely to start chemotherapy within the last 30 days of life, continue chemotherapy within two weeks of death, be admitted to the ICU, and have two or more hospitalizations or emergency room visits. Survival measured from the date of diagnosis was shorter for those undergoing radiation, 122 days (IQR 58-462) versus 474 days (IQR 225-1150). Palliative care consultations occurred later in those undergoing radiation therapy.

CONCLUSION

Radiation therapy in the last month of life occurs in younger patients with rapidly progressive cancer, who are subject to more aggressive cancer care, and have late palliative care consults.

An Analysis of Clinical and Systemic Factors Associated with Palliative Radiotherapy Delivery and Completion at the End of Life in Alberta, Canada

Radiotherapy (RT) is often utilized for symptom control at the end of life. Palliative RT (pRT) may not be taken to completion by patients, thus decreasing clinical benefits and adversely impacting resource allocation. We determined rates of incomplete pRT and examined predictors of non-completion using an electronic questionnaire. Methods: A questionnaire was embedded within the RT electronic prescribing system for all five cancer centers of Alberta, Canada, between 2017 and 2020. Prescribing radiation oncologists (ROs) were tasked with completing the questionnaire. Treatment variables were collected for 2040 patients prescribed pRT. Details on pRT courses delivered and completed were used to determine rates of incomplete RT. Electronic medical records of a subset of 367 patients randomly selected from the 2040 patients were then analyzed to examine for association of non-completion of RT with patient, disease, and therapy-related factors. Results: Overall, 10% of patients did not complete pRT. The rate of single fractions prescribed as a proportion of all RT fractions increased from 18% (pre-2017: pre-study era) to 29% (2017-2020: study era) (p < 0.0001). After conducting multivariate analysis on the overall group, multiple lifetime malignancies (OR:0.64) or increasing the number of pRT fractions (OR:0.08-0.17) were associated with non-completion. Being selected for stereotactic RT (OR:3.75) or survival > 30 days post-RT prescription (OR:2.20-5.02) were associated with greater rates of RT completion. The ROs' estimates of life expectancy at the time of RT prescription were not predictive of RT completion. In the multivariate analysis of the 367-patient subset, the presence of hepatic metastases (OR 2.59), survival 30-59 days (OR 6.61) and survival 90+ days (OR 8.18) post-RT prescription were associated with pRT completion. Only increasing pRT fractionation (OR:0.05-0.2) was associated with non-completion. Conclusion: One in ten patients prescribed pRT did not complete their treatment course. Decreasing pRT fractionation and improving prognostication in patients near the end of life may decrease rates of incomplete RT courses.

The LabPS score: Inexpensive, Fast, and Site-agnostic Survival Prediction

OBJECTIVES

To provide a widely applicable, blood-biomarker-based and performance-status-based prognostic model, which predicts the survival of patients undergoing palliative non-brain radiotherapy. This model has already been examined in a cohort of patients treated for brain metastases and performed well.

METHODS

This was a retrospective single-institution analysis of 375 patients, managed with non-ablative radiotherapy to extracranial targets, such as bone, lung, or lymph nodes. Survival was stratified by LabPS score, a model including serum hemoglobin, platelets, albumin, C-reactive protein, lactate dehydrogenase, and performance status. Zero, 0.5, or 1 point was assigned and the final point sum calculated. A higher point sum indicates shorter survival.

RESULTS

The LabPS score predicted overall survival very well (median 0.6 to 26.5 mo, 3-month rate 0% to 100%, 1-year rate 0% to 89%), P =0.0001. However, the group with the poorest prognosis (4.5 points) was very small. Most patients with comparably short survival or radiotherapy administered in the last month of life had a lower point sum. Additional prognostic factors, such as liver metastases, opioid analgesic use, and/or corticosteroid medication, were identified.

CONCLUSIONS

If busy clinicians prefer a general prognostic model rather than a panel of separate diagnosis-specific/target-specific scores, they may consider validating the LabPS score in their own practice. In resource-constrained settings, inexpensive standard blood tests may be preferable over imaging-derived prognostic information. Just like other available scores, the LabPS cannot identify all patients with very short survival.

Palliative appropriateness criteria: external validation of a new method to evaluate the suitability of palliative radiotherapy fractionation

BACKGROUND

Recently, the palliative appropriateness criteria (PAC) score, a novel metric to aid clinical decision-making between different palliative radiotherapy fractionation regimens, has been developed. It includes baseline parameters including but not limited to performance status. The researchers behind the PAC score analyzed the percent of remaining life (PRL) on treatment. The latter was accomplished by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. The purpose of the present study was to validate this novel metric.

PATIENTS AND METHODS

The retrospective validation study included 219 patients (287 courses of palliative radiotherapy). The methods were identical to those employed in the score development study. The score was calculated by assigning 1 point each to several factors identified in the original study and using the online calculator provided by the PAC developers.

RESULTS

Median survival was 6 months and death within 30 days from start of radiotherapy was recorded in 13% of courses. PRL on treatment ranged from 1 to 23%, median 8%. Significant associations were confirmed between online-calculated PAC score, observed survival, and risk of death within 30 days from the start of radiotherapy. Patients with score 0 had distinctly better survival than all other groups. The score-predicted median risk of death within 30 days from start of radiotherapy was 22% in our cohort. A statistically significant correlation was found between predicted and observed risk (p < 0.001). The original and present study were not perfectly concordant regarding number and type of baseline parameters that should be included when calculating the PAC score.

CONCLUSION

This study supports the dual strategy of PRL and risk of early death calculation, with results stratified for fractionation regimen, in line with the original PAC score study. When considering multifraction regimens, the PAC score identifies patients who may benefit from shorter courses. Additional work is needed to answer open questions surrounding the underlying components of the score, because the original and validation study were only partially aligned.

Clinical Factors Associated with 30-Day Mortality Among Patients Undergoing Brain Metastases Radiotherapy

Purpose

Existing brain metastasis prognostic models do not identify patients at risk of very poor survival after radiation therapy (RT). Identifying patient and disease risk factors for 30-day mortality (30-DM) after RT may help identify patients who would not benefit from RT.

Methods and Materials

All patients who received stereotactic radiosurgery (SRS) or whole-brain RT (WBRT) for brain metastases from January 1, 2017, to September 30, 2020, at a single tertiary care center were included. Variables regarding demographics, systemic and intracranial disease characteristics, symptoms, RT, palliative care, and death were recorded. Thirty-day mortality was defined as death within 30 days of RT completion. The Kaplan-Meier method was used to estimate median overall survival. Univariate and multivariable logistic regression models were used to assess associations between demographic, tumor, and treatment factors and 30-DM.

Results

A total of 636 patients with brain metastases were treated with either WBRT (n = 117) or SRS (n = 519). The most common primary disease types were non-small cell lung (46.7%) and breast (19.8%) cancer. Median survival time was 6 months (95% CI, 5-7 months). Of the 636 patients, 75 (11.7%) died within 30 days of RT. On multivariable analysis, progressive intrathoracic disease (hazard ratio [HR], 4.67; 95% CI, 2.06-10.60; P = .002), progressive liver and/or adrenal metastases (HR, 2.20; 95% CI, 1.16-3.68; P = .02), and inpatient status (HR, 4.51; 95% CI, 1.78-11.42; P = .002) were associated with dying within 30 days of RT. A higher Karnofsky Performance Status (KPS) score (HR, 0.95; 95% CI, 0.93-0.97; P < .001), synchronous brain metastases at time of initial diagnosis (HR, 0.45; 95% CI, 0.21-0.96; P = .04), and outpatient palliative care utilization (HR, 0.45; 95% CI, 0.20-1.00; P = .05) were associated with surviving more than 30 days after RT.

Conclusions

Multiple factors including a lower KPS, progressive intrathoracic disease, progressive liver and/or adrenal metastases, and inpatient status were associated with 30-DM after RT. A higher KPS, brain metastases at initial diagnosis, and outpatient palliative care utilization were associated with survival beyond 30 days. These data may aid in identifying which patients may benefit from brain metastasis-directed RT.

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.

Palliative Appropriateness Criteria: A Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation

Purpose: To describe a novel metric to aid clinical decision making between shorter versus longer palliative radiotherapy (PRT) regimens using objective patient factors. Materials and Methods: Patients receiving PRT at a single institution between 2014 and 2018 were reviewed. The time between PRT start and finish was calculated and divided by overall survival (in days from start of PRT) to generate the percent of remaining life (PRL). This value was compared across various clinical factors using the Kruskal-Wallis test. Factors identified with a significance level p < 0.01 were included in a novel Palliative Appropriateness Criteria Score (PACS) and were included in an online risk assessment tool to assist clinicians in patient-specific fractionation decisions. Results: Totally 1027 courses of PRT were analyzed. Median age was 64 years; Eastern Cooperative Oncology Group (ECOG) performance status was 3-4 in 22%. Primary malignancies included were lung (38%), breast (13.8%), prostate (9.3%), and other (39%). The indication for PRT was pain (61%), neurological (21%), or other (18%). Palliative regimens included 199 (19.4%) receiving single fraction, 176 (17.1%) receiving 2-5 fractions, and 652 (63.5%) receiving 10 fractions. Median follow-up was 83 days overall and 437 days for patients alive at last follow-up. Factors significantly associated with increased PRL (and included in the PACS) were male gender, ECOG 3-4, lung or "other" primary diagnosis (vs. breast or prostate), PRT indication (neurological dysfunction vs. pain/other), inpatient status, and extraosseous sites treatment. Death within 30 days was significantly associated with high-risk PACS categorization, regardless of fractionation scheme (p < 0.001). Conclusions: The PACS is a novel metric for evaluating the utility of PRT regimens to improve clinical decision making. Single fraction is associated with low PRL. When considering multifraction PRT regimens, the PACS identifies patients who may benefit from shorter courses of PRT and alternatively, low-risk patients for whom a more protracted course is reasonable. Prospective external validation is warranted.

DART: diagnostic-CT-enabled planning: a randomized trial in palliative radiation therapy (study protocol)

BACKGROUND

Palliative radiotherapy (PRT) is an effective treatment for managing symptoms of advanced cancer. At least half of all radiation treatments are delivered with palliative intent, aimed at relieving symptoms, such as pain or shortness of breath. Symptomatic patients must receive PRT quickly, therefore expeditious treatment planning is essential. Standard radiation planning requires a dedicated CT scan acquired at the cancer centre, called a 'CT simulation', which facilitates treatment planning (i.e. tumor delineation, placement of radiation beams and dose calculation). However, the CT simulation process creates a bottleneck and often leads to delays in starting treatment. Other researchers have indicated that CT simulation can be replaced by the use of standard diagnostic CT scans for target delineation and planning, which are normally acquired through the radiology department as part of standard patient workup. The goals of this feasibility study are to assess the efficacy, acceptability and scalability of diagnostic-CT-enabled planning, compared to conventional CT simulation planning, for patients receiving PRT to bone, soft tissue and lung disease.

METHODS

This is a randomized, phase II study, with 33 PRT patients to be randomized in a 1:2 ratio between conventional CT simulation (Arm 1), and the diagnostic CT enabled planning workflow (Arm 2). Patients will be stratified by treatment target volume (bone and soft tissue metastasis vs. primary or metastatic intrathoracic disease targets). The primary endpoint is the amount of time the patient spends at the cancer centre. Secondary endpoints include efficacy (rate of plan deliverability and rate of plan acceptability on blinded dose distribution review), stakeholder acceptability (based on patient and clinician perception of acceptability questionnaires) and scalability.

DISCUSSION

This study will investigate the efficacy, acceptability and scalability of a "sim-free" PRT pathway compared to conventional CT simulation. The workflow may provide opportunity for resource optimization by using pre-existing diagnostic imaging and requires minimal investment due to its similarity to current PRT models. It also offers potential benefit to patients by eliminating an imaging procedure, reducing the amount of time spent at the cancer centre, and expediting time to treatment.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05233904. Date of registration: February 10, 2022; current version: 1.4 on April 29, 2022.

Improving the Integration between Palliative Radiotherapy and Supportive Care: A Narrative Review

Palliative radiotherapy (PRT) is known to be effective in relieving cancer related symptoms. However, many studies and clinical practice show several barriers hindering its use and worsening the quality of patient support during PRT. Various solutions were proposed to overcome these barriers: training on PRT for supportive and palliative care specialists and training on palliative care for radiation oncologists, and introduction of pathways and organizational models specifically dedicated to PRT. Evidence on innovative organizational models and mutual training experiences is few and sparse. Therefore, the aim of this literature review is to present a quick summary of the information available on improving the PRT quality through training, new pathways, and innovative organizational models. The majority of studies on the integration of PRT with other palliative and supportive therapies present low levels of evidence being mostly retrospective analyses. However, it should be emphasized that all reports uniformly showed advantages coming from the integration of PRT with supportive therapies. To actively participate in the integration of PRT and palliative care, providing comprehensive support to the needs of patients with advanced cancer, radiation oncologists should not only plan PRT but also: (i) assess and manage symptoms and stress, (ii) rapidly refer patients to specialists in management of more complex symptoms, and (iii) participate in multidisciplinary palliative care teams. To this end, improved education in palliative care both in residency schools and during professional life through continuous medical education is clearly needed. In particular, effective training is needed for radiotherapy residents to enable them to provide patients with comprehensive palliative care. Therefore, formal teaching of adequate duration, interactive teaching methods, attendance in palliative care services, and education in advanced palliative care should be planned in post-graduated schools of radiotherapy.

Identifying patients with malignant spinal cord compression (MSCC) near end of life who can benefit from palliative radiotherapy

BACKGROUND

A previous score predicted death ≤ 2 months following radiotherapy for MSCC. For patients with a high probability of early death, best supportive care was recommended. However, some of these patients may benefit from radiotherapy regarding preservation or improvement of motor function. To identify these patients, an additional score was developed.

METHODS

Pre-treatment factors plus radiotherapy regimen were retrospectively evaluated for successful treatment (improved motor function or remaining ambulatory without aid) and post-treatment ambulatory status in 545 patients who died ≤ 2 months. Factors included age, interval from tumor diagnosis until MSCC, visceral metastases, further bone metastases, primary tumor type, sex, time developing motor deficits, pre-treatment ambulatory status, and number of affected vertebrae. Factors significant on both multivariable analyses were included in the score (worse outcomes 0 points, better outcomes 1 point).

RESULTS

On multivariable analyses, myeloma/lymphoma, time developing motor deficits > 14 days, and pre-treatment ambulatory status were significantly associated with both successful treatment and ambulatory status, affection of 1-2 vertebrae with successful treatment only. On univariable analyses, 1 × 8 and 5 × 4 Gy were not inferior to 5 × 5 Gy and longer-course regimens. Considering the three factors significant for both endpoints, three groups were designed (0, 1, 2-3 points) with treatment success rates of 4%, 15% and 39%, respectively (p < 0.0001), and post-treatment ambulatory rates of 4%, 43% and 86%, respectively (p < 0.0001).

CONCLUSION

This score helps identify patients with MSCC who appear to benefit from palliative radiotherapy in terms of improved motor function or remaining ambulatory in spite of being near end of life.

Anti-tumor treatment and healthcare consumption near death in the era of novel treatment options for patients with melanoma brain metastases

Background

Effective systemic treatments have revolutionized the management of patients with metastatic melanoma, including those with brain metastases. The extent to which these treatments influence disease trajectories close to death is unknown. Therefore, this study aimed to gain insight into provided treatments and healthcare consumption during the last 3 months of life in patients with melanoma brain metastases.

Methods

Retrospective, single-center study, including consecutive patients with melanoma brain metastases diagnosed between June-2015 and June-2018, referred to the medical oncologist, and died before November-2019. Patient and tumor characteristics, anti-tumor treatments, healthcare consumption, presence of neurological symptoms, and do-not-resuscitate status were extracted from medical charts.

Results

100 patients were included. A BRAF-mutation was present in 66 patients. Systemic anti-tumor therapy was given to 72% of patients during the last 3 months of life, 34% in the last month, and 6% in the last week. Patients with a BRAF-mutation more frequently received systemic treatment during the last 3 (85% vs. 47%) and last month (42% vs. 18%) of life than patients without a BRAF-mutation. Furthermore, patients receiving systemic treatment were more likely to visit the emergency room (ER, 75% vs. 36%) and be hospitalized (75% vs. 36%) than those who did not.

Conclusion

The majority of patients with melanoma brain metastases received anti-tumor treatment during the last 3 months of life. ER visits and hospitalizations occurred more often in patients on anti-tumor treatment. Further research is warranted to examine the impact of anti-tumor treatments close to death on symptom burden and care satisfaction.

Shortened Palliative Radiotherapy Results in a Lower Rate of Treatment During the Last Month of Life

Introduction

Palliative radiotherapy (PRT) during the last month of life (PRT30) should be avoided because relevant clinical benefits are unlikely to occur. While traditional short-course fractionation regimens are suitable for most patients, a minority may derive gains from higher doses of PRT. Compared to older regimens such as 13 fractions of 3 Gy, more hypofractionated, non-ablative concepts with reduced overall treatment time are not well studied.

Methods

Retrospective analysis (2017-2020) of 107 patients treated to metastatic lesions (one or two target volumes per patient) with traditional >2 weeks regimens or newer ≤2 weeks regimens, e.g. seven fractions of 5 Gy or five fractions of 6 Gy.

Results

Failure to complete radiotherapy was registered in 8% of patients (traditional fractionation) and 1%, respectively (p=0.12). Moderate rates of PRT30 were observed (11% and 6%, respectively, p=0.44). PRT30 was more likely in patients irradiated for brain or lymph node metastases. Utilization of newer ≤2 weeks regimens was highest in 2020, presumably as a result of the coronavirus disease 2019 (COVID-19) pandemic.

Conclusion

The implementation of newer fractionation regimens for selected patients has resulted in acceptable rates of non-completion and PRT30. Optimal selection criteria remain to be determined. Established, guideline-endorsed short-course regimens such as five fractions of 4 Gy and 8-Gy single fractions continue to represent important PRT approaches.

Glial activation positron emission tomography imaging in radiation treatment of breast cancer brain metastases

Brain metastases affect more breast cancer patients than ever before due to increased overall patient survival with improved molecularly targeted treatments. Approximately 25–34% of breast cancer patients develop brain metastases in their lifetime. Due to the blood–brain barrier (BBB), the standard treatment for breast cancer brain metastases (BCBM) is surgery, stereotactic radiosurgery (SRS) and/or whole brain radiation therapy (WBRT). At the cost of cognitive side effects, WBRT has proven efficacy in treating brain metastases when used with local therapies such as SRS and surgery. This review investigated the potential use of glial activation positron emission tomography (PET) imaging for radiation treatment of BCBM. In order to put these studies into context, we provided background on current radiation treatment approaches for BCBM, our current understanding of the brain microenvironment, its interaction with the peripheral immune system, and alterations in the brain microenvironment by BCBM and radiation. We summarized preclinical literature on the interactions between glial activation and cognition and clinical studies using translocator protein (TSPO) PET to image glial activation in the context of neurological diseases. TSPO-PET is not employed clinically in assessing and guiding cancer therapies. However, it has gained traction in preclinical studies where glial activation was investigated from primary brain cancer, metastases and radiation treatments. Novel glial activation PET imaging and its applications in preclinical studies using breast cancer models and glial immunohistochemistry are highlighted. Lastly, we discuss the potential clinical application of glial activation imaging to improve the therapeutic ratio of radiation treatments for BCBM.

Dual Use of the METSSS Model Predicting Survival After Palliative Radiotherapy: An Exploratory Analysis

INTRODUCTION

The recently published METSSS model, which was developed for prediction of survival after palliative radiotherapy, includes age, sex, cancer type, localization of distant metastases, Charlson-Deyo comorbidity score and radiotherapy site. Its ability to predict other relevant endpoints has not been studied yet. Therefore, this exploratory study analyzed the endpoints "unplanned termination of radiotherapy" and "treatment in the last 30 days of life" in the METSSS-defined risk groups (low/medium/high).

METHODS

The risk group was assigned in the METSSS online calculator for our patient cohort with non-hematological malignancies treated between 2009 and 2014 during the first course of treatment (resembling details of the original METSSS study). All patients were treated with classical palliative dose/fractionation regimes such as five fractions of 4 Gy, 10 fractions of 3 Gy or 13 fractions of 3 Gy. No stereotactic high-dose radiation was utilized. Given that single-fraction radiotherapy cannot be discontinued, patients treated with 8 Gy x1 for uncomplicated painful bone metastases were excluded. Both completed and discontinued multi-fraction radiotherapy courses (at least two fractions intended) were included.

RESULTS

The study included 290 patients, 19 of whom failed to complete their prescribed course of palliative radiotherapy (7%). Thirty-nine (13%) were irradiated in the last 30 days of life. Only one patient was classified as low-risk according to the METSSS model (medium: 15, high: 274). Only Eastern Cooperative Oncology Group (ECOG) performance status (PS) was significantly associated with incomplete treatment. All 16 patients with low/medium METSSS risk scores completed their prescribed course of radiotherapy, compared to the 93% completion rate in the high-risk group, p=0.41. With regard to treatment in the last 30 days of life, ECOG PS, metastases to brain, liver and lung, and the number of prescribed fractions were statistically significant. One patient with a low/medium METSSS risk score was treated in the last 30 days of life (6%), compared to 14% in the high-risk group, p=0.49.

CONCLUSION

 Unexpected imbalances in the METSSS risk group size resulted in lower statistical power than anticipated. Patients with low/medium METSSS risk scores performed numerically better. However, other predictive factors, especially ECOG PS, which is not part of the METSSS model, maybe more relevant. Further efforts towards the application of the model beyond its original objective cannot be recommended.

The effect of a palliative care pathway on medical interventions at the end of life: a pre-post-implementation study

PURPOSE

Adequate integration of palliative care in oncological care can improve the quality of life in patients with advanced cancer. Whether such integration affects the use of diagnostic procedures and medical interventions has not been studied extensively. We investigated the effect of the implementation of a standardized palliative care pathway in a hospital on the use of diagnostic procedures, anticancer treatment, and other medical interventions in patients with incurable cancer at the end of their life.

METHODS

In a pre- and post-intervention study, data were collected concerning adult patients with cancer who died between February 2014 and February 2015 (pre-PCP period) or between November 2015 and November 2016 (post-PCP period). We collected information on diagnostic procedures, anticancer treatments, and other medical interventions during the last 3 months of life.

RESULTS

We included 424 patients in the pre-PCP period and 426 in the post-PCP period. No differences in percentage of laboratory tests (85% vs 85%, p = 0.795) and radiological procedures (85% vs 82%, p = 0.246) were found between both groups. The percentage of patients who received anticancer treatment or other medical interventions was lower in the post-PCP period (40% vs 22%, p < 0.001; and 42% vs 29%, p < 0.001, respectively).

CONCLUSIONS

Implementation of a PCP resulted in fewer medical interventions, including anticancer treatments, in the last 3 months of life. Implementation of the PCP may have created awareness among physicians of patients' impending death, thereby supporting caregivers and patients to make appropriate decisions about medical treatment at the end of life.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register; clinical trial number: NL 4400 (NTR4597); date registrated: 2014-04-27.

The LabBM score is an excellent survival prediction tool in patients undergoing palliative radiotherapy

Background and aim

The prognostic assessment of patients referred for palliative radiotherapy can be conducted by site-specific scores. A quick assessment that would cover the whole spectrum could simplify the working day of clinicians who are not specialists for a particular disease site. This study evaluated a promising score, the LabBM (validated for brain metastases), in patients treated for other indications.

Materials and methods

The LabBM score was calculated in 375 patients by assigning 1 point each for C-reactive protein and lactate dehydrogenase above the upper limit of normal, and 0.5 points each for hemoglobin, platelets and albumin below the lower limit of normal. Uni- and multivariate analyses were performed.

Results

Median overall survival gradually decreased with increasing point sum (range 25.1-1.1 months). When grouped according to the original three-tiered model, excellent discrimination was found. Patients with 0-1 points had a median survival of 15.7 months. Those with 1.5-2 points had a median survival of 5.8 months. Finally, those with 2.5-3.5 points had a median survival of 3.2 months (all p-values ≤ 0.001).

Conclusion

The LabBM score, which is derived from inexpensive blood tests and easy to use, stratified patients into three very distinct prognostic groups and deserves further validation.

The palliative clinical specialist radiation therapist: A CAMRT White Paper

Palliative radiation therapy (pRT) is an effective tool for people with incurable cancer, in the treatment of many cancer-related symptoms such as pain, bleeding and dyspnea. As utilization rates for palliative radiation therapy increase, the demands on the healthcare system continue to grow. Radiation Therapists with advanced knowledge, skills and judgements began demonstrating their ability to practice autonomously in 2004, with the development of the Clinical Specialist Radiation Therapist (CSRT) role. Since this time, CSRTs with a specific focus in pRT (pCSRT) have been increasing in both numbers as well as their positive effects on the cancer care system. Integrating a pCSRT into the existing pRT system has resulted in increased access to and quality of pRT being delivered to palliative cancer patients. The benefits of the addition of pCSRTs to the cancer care system include increasing system capacity and increasing quality of care. This white paper provides information related to the improvements that can be realized in a RT program related to the care and treatment of its palliative patients by adding a pCSRT to the interprofessional healthcare team and suggest it as one of many strategies that can be undertaken to make improvements to access and quality of care.

[Ethical stakes in palliative care in radiation oncology]

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

Patterns of Specialty Palliative Care Utilization Among Patients Receiving Palliative Radiation Therapy

CONTEXT

Palliative radiation therapy (RT) is frequently used to ameliorate cancer-associated symptoms and improve quality of life.

OBJECTIVES

To examine how palliative care (PC) as a specialty is integrated at the time of RT consultation for patients with advanced cancer.

METHODS

We retrospectively reviewed 162 patients with metastatic cancer who received palliative RT at our institution (7/2017-2/2018). Fisher's exact test identified differences in incidence of receiving any specialty PC. Logistic regression analyses determined predictors of receiving PC.

RESULTS

Of the 74 patients (46%) who received any specialty PC, 24 (32%) initiated PC within four weeks of RT consultation. The most common reasons for specialty PC initiation were pain (64%) and goals of care/end-of-life care management (23%). Referrals to specialty PC were made by inpatient care teams (48.6%), medical oncologists (48.6%), radiation oncologists (1.4%), and self-referring patients (1.4%). Patients with pain at RT consultation had a higher incidence of receiving specialty PC (58.7% vs. 37.4%, P = 0.0097). There was a trend toward decreased PC among patients presenting with neurological symptoms (34.8% vs. 50%, P = 0.084). On multivariable analysis, receiving specialty PC significantly differed by race (non-white vs. white, odds ratio [OR] = 6.295 [95% CI 1.951-20.313], P = 0.002), cancer type (lung vs. other histology, OR = 0.174 [95% CI 0.071-0.426], P = 0.0006), and RT consultation setting (inpatient vs. outpatient, OR = 3.453 [95% CI 1.427-8.361], P = 0.006).

CONCLUSION

Fewer than half of patients receiving palliative RT utilized specialty PC. Initiatives are needed to increase PC, especially for patients with lung cancer and neurological symptoms, and to empower radiation oncologists to refer patients to specialty PC.

Efficacy and Survival after Palliative Radiotherapy for Malignant Pulmonary Obstruction

Introduction: The purpose of this study was to determine the efficacy of palliative radiotherapy (PRT) for patients with pulmonary obstruction from advanced malignancy and identify factors associated with lung re-expansion and survival. Materials and Methods: We reviewed all patients treated with PRT for malignant pulmonary obstruction (n = 108) at our institution between 2010 and 2018. Radiographic evidence of lung re-expansion was determined through review of follow-up CT or chest X-ray. Cumulative incidence of re-expansion and overall survival (OS) were estimated using competing risk methodology. Clinical characteristics were evaluated for association with re-expansion, OS, and early mortality. Treatment time to remaining life ratio (TT:RL) was evaluated as a novel metric for palliative treatment. Results: Eighty-one percent of patients had collapse of an entire lung lobe, 46% had Eastern Cooperative Oncology Group (ECOG) performance status 3-4, and 64% were inpatient at consultation. Eighty-four patients had follow-up imaging available, and 25 (23%) of all patients had lung re-expansion at median time of 35 days. Rates of death without re-expansion were 38% and 65% at 30 and 90 days, respectively. Median OS was 56 days. Death within 30 days of PRT occurred in 38%. Inpatients and larger tumors trended toward lower rates of re-expansion. Notable factors associated with OS were re-expansion, nonlung histology, tumor size, and performance status. Median TT:RL was 0.11 and significantly higher for subgroups: ECOG 3-4 (0.19), inpatients (0.16), patients with larger tumors (0.14), those unfit for systemic therapy (0.17), and with 10-fraction PRT (0.14). Conclusion: One-fourth of patients experienced re-expansion after PRT for malignant pulmonary obstruction. Survival is poor and a significant proportion of remaining life may be spent on treatment. Careful consideration of these clinical factors is recommended when considering PRT fractionation.

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

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Survival prognostication and patient selection remain challenging tasks.

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

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

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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.

Risk Stratification for Imminent Risk of Death at the Time of Palliative Radiotherapy Consultation

This cohort study of patients with advanced cancer who received palliative radiotherapy within 30 days of death assesses models of prognostic criteria for providing radiotherapy at the end of life and compares outcomes with similar prognostic tools.

30-Day Mortality Following Palliative Radiotherapy

Purpose

30-day mortality (30-DM) is a parameter with widespread use as an indicator of avoidance of harm used in medicine. Our objective is to determine the 30-DM followed by palliative radiation therapy (RT) in our department and to identify potential prognosis factors.

Material/Methods

We conducted a retrospective cohort study including patients treated with palliative RT in our center during 2018 and 2019. Data related to clinical and treatment characteristics were collected.

Results

We treated 708 patients to whom 992 palliative irradiations were delivered. The most frequent primary tumor sites were lung (31%), breast (14.8%), and gastrointestinal (14.8%). Bone was the predominant location of the treatment (56%), and the use of single doses was the preferred treatment schedule (34.4%). The 30-DM was 17.5%. For those who died in the first month the median survival was 17 days. Factors with a significant impact on 30-DM were: male gender (p < 0.0001); Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) of 2–3 (p = 0.0001); visceral metastases (p = 0.0353); lung, gastrointestinal or urinary tract primary tumors (p = 0.016); and single dose RT (p = <0.0001). In the multivariate analysis, male gender, ECOG PS 2–3, gastrointestinal and lung cancer were found to be independent factors related to 30-DM.

Conclusion

Our 30-DM is similar to previous studies. We have found four clinical factors related to 30-DM of which ECOG was the most strongly associated. This data may help to identify terminally ill patients with poor prognosis in order to avoid unnecessary treatments.

Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care

BACKGROUND

Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals.

MATERIALS AND METHODS

All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed.

RESULTS

In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045).

CONCLUSIONS

Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.

Timing of Urgent Inpatient Palliative Radiation Therapy

Purpose

Urgent indications for palliative radiation therapy (RT) include malignant spinal cord compression, symptomatic brain metastases, pain, airway obstruction, and bleeding. Data on the timing of palliative RT in the inpatient setting are limited. We report our experience with inpatient palliative RT at a tertiary academic center and evaluate the effect of a dedicated inpatient palliative RT nurse practitioner (NP) on treatment timelines.

Methods and Materials

We performed a retrospective, single-institution review of 219 inpatients consulted for RT to sites of metastatic disease between May 2012 and May 2018. We compared time-to-treatment intervals before and after integrating an NP for palliative RT in August 2017.

Results

The median age of the 219 patients receiving RT was 61 years (interquartile range [IQR], 51-69 years). The most frequent indications were symptomatic brain metastases (73 patients [33%]), pain (61 patients [28%]), and cord/cauda compression (48 patients [22%]). The median time from consultation request to consult was 1 day (IQR, 0-2 days), and the median time from consultation request to first RT fraction was 3 days (IQR, 2-6 days). The median time from consultation request to RT was shorter for cord compression (2 [IQR, 1-4] days) than for pain (5 [IQR, 2-7] days) (P = .001) or symptomatic brain metastases (3 [IQR, 1-6] days; P = .037). With an NP, patients were more likely to undergo same-day consultation and simulation (75% vs 60%; P = .045), which was associated with shorter median duration from consultation to initiation of RT (1 [IQR, 0-3] days vs 4 [IQR, 2-7] days; P <.001). After the integration of an NP for palliative RT, patients had a higher median Karnofsky Performance Score (70 [IQR, 60-80] vs 50 [IQR, 40-60]; P < .001) and were more likely to complete their prescribed RT course (93% vs 82%; P = .05)

Conclusions

Time from consultation request to RT is necessarily short for urgent inpatient palliative RT. Advanced practice providers may facilitate and potentially expedite treatment, with significantly shorter times to treatment among patients who undergo same-day consultation and simulation.

Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries

CONTEXT

Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area.

OBJECTIVES

To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries.

METHODS

A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life.

RESULTS

We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%).

CONCLUSION

Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.

Process mining to optimize palliative patient flow in a high-volume radiotherapy department

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Management of palliative patients can be often out of standard clinical pathways.

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Process mining methodology has still not been exploited for palliative patients.

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Process discovery of event-log highlighted current workflow complexity/ weaknesses.

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Conformance checking evaluated how a set of events-log flow through a given model.

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Palliative patient patterns of care can be tracked and monitored by process mining.

Introduction

In radiotherapy, palliative patients are often suboptimal managed and patients experience long waiting times. Event-logs (recorded local files) of palliative patients, could provide a continuative decision-making system by means of shared guidelines to improve patient flow. Based on an event-log analysis, we aimed to accurately understand how to successively optimize patient flow in palliative care.

Methods

A process mining methodology was applied on palliative patient flow in a high-volume radiotherapy department. Five hundred palliative radiation treatment plans of patients with bone and brain metastases were included in the study, corresponding to 290 patients treated in our department in 2018. Event-logs and the relative attributes were extracted and organized. A process discovery algorithm was applied to describe the real process model, which produced the event-log. Finally, conformance checking was performed to analyze how the acquired event-log database works in a predefined theoretical process model.

Results

Based on the process discovery algorithm, 53 (10%) plans had a dose prescription of 8 Gy, 249 (49.8%) plans had a dose prescription of 20 Gy and 159 (31.8%) plans had a dose prescription of 30 Gy. The remaining 39 (7.8%) plans had different dose prescriptions. Considering a median value, conformance checking demonstrated that event-logs work in the theoretical model.

Conclusions

The obtained results partially validate and support the palliative patient care guideline implemented in our department. Process mining can be used to provide new insights, which facilitate the improvement of existing palliative patient care flows.

A Canadian experience of palliative advanced practice radiation therapy TIPS: Training, implementation, practice and sustainability

The concept of the Advanced Practice Radiation Therapist (APRT) was created in 2004, in response to pressures on the radiation treatment sector in Ontario. This led to development, piloting and integration of the Clinical Specialist Radiation Therapist (CSRT) into Ontario's cancer care framework. A national certification process, competency profile and protected title of APRT(T) were established in 2017, under the Canadian Association of Medical Radiation Technologists (CAMRT), in collaboration with Cancer Care Ontario/Ontario Health. This report describes the approach to development, validation and measuring impact of the CSRT role in Ontario, specifically in palliative care (pCSRT). It also presents information to assist jurisdictions interested in developing a pCSRT position, describing competency development, assessment, and assumption of practice, and providing some keys to success. This is foundational for consistent expansion of the pCSRT role to other regions to continue to increase system capacity while improving the quality of cancer care.

Expansion of the LabBM Score: Is the LabPS the Best Tool Predicting Survival in Patients With Brain Metastases?

OBJECTIVES

The objective of this study were to improve the 3-tiered, purely biomarker-based LabBM score, which predicts the survival of patients with brain metastases, by adding the well-established prognostic factor performance status (PS), and to define its role in comparison with the recently proposed Extracranial-Graded Prognostic Assessment score, which is based on the well-known Diagnosis-specific Graded Prognostic Assessment and 2 of the same biomarkers.

MATERIALS AND METHODS

This was a retrospective single-institution analysis of 212 patients, managed with upfront brain irradiation. Survival was stratified by LabBM and LabPS score. Each included serum hemoglobin, platelets, albumin, C-reactive protein, and lactate dehydrogenase (plus PS for the LabPS). Zero, 0.5, or 1 point was assigned and the final point sum calculated. A higher point sum indicates shorter survival.

RESULTS

The new LabPS score predicted overall survival very well (median: 12.1 to 0.7 mo, 1-y rate: 52% to 0%), P=0.0001. However, the group with the poorest prognosis (3 or 3.5 points) was very small (4%). Most patients with comparably short survival had a lower point sum. The LabPS score failed to outperform the recently proposed Extracranial-Graded Prognostic Assessment score.

CONCLUSIONS

Integration of blood biomarkers should be considered when attempting to develop improved scores. Additional research is needed to improve the tools which predict short survival, because many of these patients continue to go undetected with all available scores.

Palliative Radiotherapy Produced Spectacular Improvement in a Terminally Ill Colorectal Carcinoma Patient With Severe Pain and Duodenal Bleeding

Colorectal cancer has a devastating effect on the quality of life, and the treatment of active intestinal bleeding in colorectal cancer is a real challenge at the end of life. This case report presents a spectacular effect of an unusual palliative treatment strategy in a middle-aged home hospice patient with severe pain and persistent duodenal bleeding secondary to its neoplastic infiltration. Palliative radiotherapy (RT) significantly improved pain control, terminated the duodenal bleeding, and allowed successful treatment of deep vein thrombosis, previously impossible because of the bleeding. It also made the patient independent of otherwise unavoidable transfusions, thus improving his quality of life. In our patient, RT played a leading role in restoring general fitness and, accordingly, mental state improvement. Our case demonstrates that palliative RT may be a valuable treatment option in cases similar to ours. Still, careful assessment of risks and benefits is always mandatory.

Palliative Radiotherapy During the Last Month of Life: Have COVID-19 Recommendations Led to Reduced Utilization?

BACKGROUND/AIM

The study aimed to evaluate practice changes in the time period of the early wave of the COVID-19 pandemic.

PATIENTS AND METHODS

This was a retrospective single institution study. We defined palliative radiotherapy (PRT) initiated before Saturday, March 14^th as pre-COVID and PRT initiated later as during-COVID (through June 30^th).

RESULTS

National COVID-19 recommendations led to a significant decrease in PRT with 10 or more fractions, while re-irradiation and radiotherapy during the final 30 days of life were equally common before and after these recommendations had been issued in March 2020.

CONCLUSION

Rapid adoption of modified PRT regimens was feasible. However, the challenge of overtreatment in the final phase of the disease, due to inaccurate survival prediction, persisted.

Physician-Predicted Prognosis and Palliative Radiotherapy Treatment Utilization at the End of Life: An Audit of a Large Cancer Center Network

CONTEXT

At our institution, clinical pathways capture physicians' prognostication of patients being evaluated for palliative radiotherapy. We hypothesize a low utilization rate of long-course radiotherapy (LCRT) and stereotactic ablative radiotherapy (SAbR) among patients seen at the end of life, especially those with physician-predicted poor prognosis.

OBJECTIVE

To analyze utilization rates and predictors of LCRT and SAbR at the end of life.

METHODS

A retrospective review was conducted on patients who were evaluated for palliative radiotherapy between January 2017 and August 2019 and died within 90 days of consultation. Binary logistic regression was used to identify predictors for utilization of LCRT (≥10 fractions) and SAbR.

RESULTS

A total of 1608 patients were identified, of which 1038 patients (64.6%) were predicted to die within a year. Six hundred ninety-three patients (66.8%) out of 1038 were prescribed LCRT or SAbR. On a multivariate analysis, patients were less likely to be prescribed LCRT if treated at an academic site (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.23-0.39; P < 0.01) and treated for bone metastases (OR, 0.08; 95% CI, 0.05-0.11; P < 0.01) or other nonbrain/nonbone metastases (OR, 0.19; 95% CI, 0.13-0.30; P < 0.01). SAbR was less likely to be prescribed among patients predicted to die within a year (OR, 0.09; 95% CI, 0.06-0.16; P < 0.01), treated for bone metastases (OR, 0.13; 95% CI, 0.07-0.22; P < 0.01), with poor performance status (OR, 0.51; 95% CI, 0.31-0.85; P = 0.01), and with a breast primary (OR, 0.35; 95% CI, 0.15-0.82; P = 0.02).

CONCLUSION

Although most patients were predicted to have a limited prognosis, LCRT and SAbR were commonly prescribed at the end of life.

External validation of life expectancy prognostic models in patients evaluated for palliative radiotherapy at the end-of-life

BACKGROUND

The TEACHH and Chow models were developed to predict life expectancy (LE) in patients evaluated for palliative radiotherapy (PRT). We sought to validate the TEACHH and Chow models in patients who died within 90 days of PRT consultation.

METHODS

A retrospective review was conducted on patients evaluated for PRT from 2017 to 2019 who died within 90 days of consultation. Data were collected for the TEACHH and Chow models; one point was assigned for each adverse factor. TEACHH model included: primary site of disease, ECOG performance status, age, prior palliative chemotherapy courses, hospitalization within the last 3 months, and presence of hepatic metastases; patients with 0-1, 2-4, and 5-6 adverse factors were categorized into groups (A, B, and C). The Chow model included non-breast primary, site of metastases other than bone only, and KPS; patients with 0-1, 2, or 3 adverse factors were categorized into groups (I, II, and III).

RESULTS

A total of 505 patients with a median overall survival of 2.1 months (IQR: 0.7-2.6) were identified. Based on the TEACHH model, 10 (2.0%), 387 (76.6%), and 108 (21.4%) patients were predicted to live >1 year, >3 months to ≤1 year, and ≤3 months, respectively. Utilizing the Chow model, 108 (21.4%), 250 (49.5%), and 147 (29.1%) patients were expected to live 15.0, 6.5, and 2.3 months, respectively.

CONCLUSION

Neither the TEACHH nor Chow model correctly predict prognosis in a patient population with a survival <3 months. A better predictive tool is required to identify patients with short LE.

Evaluation of imaging findings and prognostic factors after whole-brain radiotherapy for carcinomatous meningitis from breast cancer: A retrospective analysis

This study aimed to evaluate the imaging findings and prognostic factors after whole-brain radiotherapy in patients with carcinomatous meningitis from breast cancer.A retrospective analysis of imaging data and prognostic factors was performed in patients treated with whole-brain radiotherapy or whole-brain/spine radiotherapy immediately after the first diagnosis of carcinomatous meningitis from breast cancer at our hospital from January 1, 2010 to December 31, 2018. Statistical significance was set at P < .05 (two-tailed).All patients (n = 31) were females with the mean age of 58.0 ± 11.0 years. The breast cancer subtypes were luminal (n = 14, 45.1%), human epidermal growth factor receptor 2 (HER2)-positive (n = 9, 29.0%), and triple-negative (n = 8, 26.0%) breast cancer. Brain metastasis and abnormal contrast enhancement in the sulci were observed in 21 (67.7%) and 24 (80.6%) patients, respectively. The median survival time after cancerous meningitis diagnosis was 62 (range, 6-657) days. Log-rank test showed significant differences in median survival time after cancerous meningitis diagnosis: 18.0 days for subjects treated with 30 Gy in < 10 fractions (n = 7) vs 78.5 days for subjects treated with 30 Gy in ≥10 fractions (n = 24) (P < .01) and 23.0 days for the triple-negative subtype vs 78.5 days for the other subtype (P < .01) groups. Univariate analysis using the Cox regression model showed significant differences in median survival time after cancerous meningitis diagnosis between the group treated with 30 Gy in <10 fractions and the group treated in ≥10 fractions (hazard ratio [HR] 0.08, 95% confidence interval [CI], 0.03-0.26; P < .01), and between the triple-negative subtype and the other subtypes (HR = 5.48; 95% CI, 1.88-16.0; P < .01) groups.Discontinuation of whole-brain radiotherapy and the presence of triple-negative breast cancer were indicators of poor prognosis.