Radiation therapy at the end of life: a population-based study examining palliative treatment intensity

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.

Treatment Terminations During Radiation Therapy: A 10-Year Experience

PURPOSE

Patients undergoing radiation therapy may terminate treatment for any number of reasons. The incidence of treatment termination (TT) during radiation therapy has not been studied. Herein, we present a cohort of TT at a large multicenter radiation oncology department over 10 years.

METHODS AND MATERIALS

TTs between January 2013 and January 2023 were prospectively analyzed as part of an ongoing departmental quality and safety program. TT was defined as any premature discontinuation of therapy after initiating radiation planning. The rate of TT was calculated as a percentage of all patients starting radiation planning. All cases were presented at monthly morbidity and mortality conferences with a root cause reviewed.

RESULTS

A total of 1448 TTs were identified out of 31,199 planned courses of care (4.6%). Six hundred eighty-six (47.4%) involved patients treated with curative intent, whereas 753 (52.0%) were treated with palliative intent, and 9 (0.6%) were treated for benign disease. The rate of TT decreased from 8.49% in 2013 to 3.02% in 2022, with rates decreasing yearly. The most common disease sites for TT were central nervous system (21.7%), head and neck (19.3%), thorax (17.5%), and bone (14.2%). The most common causes of TT were hospice and/or patient expiration (35.9%), patient choice unrelated to toxicity (35.2%), and clinician choice unrelated to toxicity (11.5%).

CONCLUSIONS

This 10-year prospective review of TTs identified a year-over-year decrease in TTs as a percentage of planned patients. This decrease may be associated with the addition of root cause reviews for TTs and discussions monthly at morbidity and mortality rounds, coupled with departmental upstream quality initiatives implemented over time. Understanding the reasons behind TTs may help decrease preventable TTs. Although some TTs may be unavoidable, open discourse and quality improvement changes effectively reduce TT incidents over time.

Association of patient socioeconomic status with outcomes after palliative treatment for disseminated cancer

BACKGROUND

Palliative treatment has been associated with improved quality of life and survival for a wide variety of metastatic cancers. However, it is unclear whether the benefits of palliative treatment are uniformly experienced across the US cancer population. We evaluated patterns and outcomes of palliative treatment based on socioeconomic, sociodemographic and treating facility characteristics.

METHODS

Patients diagnosed between 2008 and 2019 with Stage IV primary cancer of nine organ sites were analyzed in the National Cancer Database. The association between identified variables, and outcomes concerning the administration of palliative treatment were analyzed with multivariable logistic regression and Cox proportional hazard models.

RESULTS

Overall 238,995 (23.6%) of Stage IV patients received palliative treatment, which increased over time for all cancers (from 20.7% in 2008 to 25.6% in 2019). Palliative treatment utilization differed significantly by region (West less than Northeast, OR: 0.55 [0.54-0.56], p < 0.001) and insurance payer status (uninsured greater than private insurance, OR: 1.35 [1.32-1.39], p < 0.001). Black race and Hispanic ethnicity were also associated with lower rates of palliative treatment compared to White and non-Hispanics respectively (OR for Blacks: 0.91 [0.90-0.93], p < 0.001 and OR for Hispanics: 0.79 [0.77-0.81] p < 0.001).

CONCLUSIONS

There are important differences in the utilization of palliative treatment across different populations in the United States. A better understanding of variability in palliative treatment use and outcomes may identify opportunities to improve informed decision making and optimize quality of care at the end-of-life.

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.

Use of palliative radiotherapy among patients with metastatic non-small-cell lung cancer in Puerto Rico

BACKGROUND

Palliative radiotherapy (RT) represents an important treatment opportunity for improving the quality of life in metastatic non-small cell lung cancer (NSCLC) patients through the management of symptoms within the course of the illness. The aim of the study is to determine the proportion of patients who had palliative RT within 12 months of diagnosis and evaluate the factors associated with it.

METHODS

A retrospective cohort study was performed using secondary data analysis from 2009 to 2015 from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database (PRCCR-HILD). A logistic regression model was used to examine factors associated with palliative RT.

RESULTS

Among the 929 patients identified with metastatic NSCLC, 33.80% received palliative RT within the first year after diagnosis. After adjusting for other covariates, receipt of chemotherapy (OR_Adj = 3.90; 95% CI = 2.91-5.45; P < 0.001) and presence of symptoms (OR_Adj = 1.41; 95% CI =1.00-1.98; P = 0.045) were associated with increased odds of palliative RT use. Although marginally significant, patients with private health insurance had increased odds of palliative RT use (OR_Adj = 1.50; 95% CI = 0.98-2.29; P = 0.061) when compared to beneficiaries of Medicaid, after adjusting by other covariates.

CONCLUSIONS

The results of this study reveal concerning underuse of palliative RT among patients with metastatic NSCLC in Puerto Rico. Additional research is necessary to further understand the barriers to using palliative RT on the island.

Prognostic tools for survival prediction in advanced cancer patients: A systematic review

Survival prediction for palliative cancer patients by physicians is often optimistic. Patients with a very short life expectancy (<4 weeks) may not benefit from radiation therapy (RT), as the time to maximal symptom relief after treatment can take 4-6 weeks. We aimed to identify a prognostic tool (or tools) to predict survival of less than 4 weeks and less than 3 months in patients with advanced cancer to guide the choice of radiation dose and fractionation. We searched Embase, Medline (EBSCOhost) and CINAHL (EBSCOhost) clinical databases for literature published between January 2008 and June 2018. Seventeen studies met the inclusion criteria and were included in the review. Prediction accuracy at less than 4 weeks and less than 3 months were compared across the prognostic tools. Reporting of prediction accuracy among the different studies was not consistent: the Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI) and Number of Risk Factors (NRF) best-predicted survival duration of less than 4 weeks. The PPI, performance status with Palliative Prognostic Index (PS-PPI), NRF and Survival Prediction Score (SPS) may predict 3-month survival. We recommend PPI and PaP tools to assess the likelihood of a patient surviving less than 4 weeks. If predicted to survive longer and RT is justified, the NRF tool could be used to determine survival probability less than 3 months which can then help clinicians select dose and fractionation. Future research is needed to verify the reliability of survival prediction using these prognostic tools in a radiation oncology setting.

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.

Prevalence of Treatment Burden in the Last Three Years of Life

Background: Little is known about the experience of treatment burden, or the difficulties that arise when the treatment workload overwhelms one's ability to take on treatment activities, at the end of life. Objective: We first assessed rates of treatment burden experienced by all older adults in the last three years of life. Among the subset of our sample who had multiple chronic conditions (MCCs), we determined correlates of treatment burden with sociodemographic, health, and caregiving factors. Design: We conducted a cross-sectional study using nationally representative data from the National Health and Aging Trends Study (NHATS). Setting/Subjects: Our sample included 356 adults, aged 65 years and older, who died within three years of completing the 2012 NHATS Treatment Burden Questionnaire. Our MCC cohort included only those in our sample with two or more chronic conditions. Measurements: Our measure of treatment burden included reports of difficulty in managing treatment activities, delays in treatments, or feeling that physicians asked for too much. We built a composite measure to identify burden if participants reported that at least one item occurred sometimes or often. Results: Forty-three percent of older adults in their last three years of life experienced treatment burden. Among individuals with MCCs, bivariate analysis found that treatment burden was associated with being a racial minority and having depression, anxiety, and a cancer diagnosis. These associations were not statistically significant in a multivariable model. Conclusion: Treatment burden is a common experience among older adults regardless of sociodemographic, clinical, and caregiving factors.

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.

Palliative radiotherapy: what do nurses know?

BACKGROUND

palliative radiotherapy can improve quality of life for patients who are symptomatic of advanced cancers. However, this treatment modality is underused and is often mistimed, which negates its potential benefit.

AIM

the aim of this study was to assess nursing knowledge of palliative radiotherapy in the context of caring for patients with a cancer diagnosis.

METHODS

a quantitative method of research was employed using a questionnaire to assess palliative radiotherapy knowledge among a purposive sample of 162 oncology and palliative care nurses.

FINDINGS

the response rate was 48.14%. More than half of respondents reported their knowledge of radiotherapy as insufficient for their practice and almost all agreed they would benefit from more education.

CONCLUSION

nurses require more training to identify when palliative radiotherapy would be an effective symptom control option; specific areas of focus for developing future radiotherapy educational programmes are highlighted.

Safety assessment of anticancer drugs in association with radiotherapy in metastatic malignant melanoma: a real-life report : Radiation/systemic drug combo in metastatic melanoma

PURPOSE

To assess the safety of the association of radiotherapy (RT) and systemic treatments for patients with metastatic malignant melanoma (mMM).

METHODS

A retrospective analysis included consecutive patients treated with palliative RT, and at least one line of systemic therapy for mMM between 2001 and 2016. Treatments were defined as sequential or concomitant when RT and the systemic drug were administered, respectively, at more or less than five half-lives from each other.

RESULTS

92 patients were included. They had 110 palliative RT treatments. RT was delivered with a "conventional" chemotherapy (mainly fotemustine and/or dacarbazine) and a "modern" systemic therapy (BRAF inhibitors, association of BRAF and MEK inhibitors, immunotherapy), respectively, in 88 (80%) and 22 (20%) cases. Systemic treatments and RT were mainly concurrently performed (n = 61, 55.5%). Regarding acute grade ≥ 3 toxicity, no difference was reported between sequential and concomitant groups either in the whole cohort (p = 1) or in the subgroup of patients receiving "modern" systemic therapies (p = 1). Acute and late grade ≥ 3 toxicities only occurred with vemurafenib. BRAF inhibitors and RT produced more severe infield adverse events than other associations (p = 0.001) with two deaths.

CONCLUSION

In our series, compared to sequential administration, concomitant association of systemic anticancer drugs and palliative RT did not increase toxicity in mMM patients. BRAF inhibitors and RT produced severe infield toxicities. Prospective studies are needed to better characterize the toxicity of each association.

Predictors of palliative treatment in stage IV colorectal cancer

BACKGROUND

Palliative treatment may be associated with prolonged survival and improved quality of life, but remains underutilized in stage IV colorectal (CRC). We examined a national cohort of stage IV CRC patients to determine the factors associated with palliative treatment.

METHODS

Stage IV CRC patients, classified based on their survival length (<6 months, 6-24 months, and 24 + months), were analyzed using the American College of Surgeons National Cancer Data Base (2004-2013). Multivariable analysis was performed to evaluate factors associated with palliative treatment.

RESULTS

Of 85,981 patients analyzed, 10.9% received palliative treatment. For 6-24 months survival, a more recent year of diagnosis, Medicaid, uninsured status, Mountain and Pacific regions were associated with higher odds of palliative treatment. For those who survived < 6months, older patients had lower odds, while academic centers and residence > 20 miles from treating institutions were associated with increased likelihood of palliative treatment.

CONCLUSIONS

Palliative treatment in stage IV CRC is associated with a more recent year of diagnosis, Medicaid, academic centers, Mountain and Pacific regions of the US.

Outcomes and Characteristics of Patients Treated with Emergent Palliative Radiation Therapy

PURPOSE

Emergent palliative radiation therapy (PRT) of symptomatic metastases can significantly increase the quality of life of patients with cancer. In some contexts, this treatment may be underused, but in others PRT may represent an excessively aggressive intervention. The characterization of the current use of emergent PRT is warranted for optimized value and patient-centered care.

METHODS AND MATERIALS

This study is a cross-sectional retrospective analysis of all emergent PRT courses at a single academic tertiary institution across 1 year.

RESULTS

A total of 214 patients received a total of 238 treatment courses. The most common indications were bone (39%) and brain (14%) metastases. Compared with outpatients, inpatients had lower mean survival rates (2 months vs 6 months; P < .001), higher rates of stopping treatment early (19.1% vs 9.0%; P = .034), and greater involvement of palliative care (44.8% vs 24.1%; P < .001), but the same mean planned fractions (9.10 vs 9.40 fractions; P = .669). In a multiple predictor survival analysis, palliative care involvement (P = .025), male sex (P = .001), ending treatment early (P = .011), and having 1 of 3 serious indications (airway compromise, leptomeningeal disease, and superior/inferior vena cava involvement; P = .007) were significantly associated with worse overall survival.

CONCLUSIONS

Survival is particularly poor in patients who receive emergent PRT, and patient characteristics such as functional status and indication should be considered when determining fractionation schedule and dosing. A multi-institutional study of practice patterns and outcomes is warranted.

Short-course palliative radiation therapy leads to excellent bleeding control: A single centre retrospective study

Purpose

To compare and evaluate the utility of varying hemostatic radiotherapy prescriptions for emergent palliation of bleeding tumors.

Materials and methods

This retrospective study analyzed 112 consecutive patients treated with radiotherapy for emergent palliation of bleeding tumors at an academic institution. Study endpoints included: primary bleeding control; re-bleeding rate after initial control; treatment interruption rate; overall survival; and death within 30 days of treatment.

Results

The most commonly prescribed fractionations were: 20 Gy in 5 fractions, 30 Gy in 10 fractions, and 8 Gy in a single fraction. The overall primary bleeding control rate was 89%. By location, primary bleeding control rates were 89% (31/35), 80% (16/20), 88% (14/16), 93% (13/14), 100% (9/9), and 100% (6/6) for gastrointestinal, genitourinary, head and neck, thoracic, extremity, and gynecologic sites, respectively. The overall re-bleeding rate following initial bleeding control was 25%. Female patients had a significantly reduced risk of bleeding recurrence (HR 0.18 [0.04-0.79], p = 0.02). Longer fractionation regimens (>5 fractions) were not associated with a reduced incidence of re-bleeding (p = 0.65), but were associated with more treatment interruptions (p = 0.02). The 1-year overall survival rate in this population was 24%, with mortality greater in patients with poor performance status (HR 2.99 [1.36-6.58], p = 0.007).

Conclusions

Regardless of prescription, palliative radiotherapy is highly effective for primary bleeding control, with both long and short regimens demonstrating equal hemostatic effect and durability in the emergent setting. Longer radiotherapy regimens (>5 fractions), however, are accompanied by increased treatment interruptions and hospital days. Therefore, shorter hemostatic regimens (<5 fractions) are preferable in this palliative setting, with respect to minimizing treatment burden for patients while achieving symptomatic relief.

Is specialized palliative cancer care associated with use of antineoplastic treatment at the end of life? A population-based cohort study

BACKGROUND

The use of chemotherapy in the last 14 days of life should be as low as possible.

AIM

To study the factors related to the use of chemotherapy in the last 14 days of life and the factors related to concurrent antineoplastic treatment and specialized palliative care.

DESIGN

This was a population-based cohort study. The data were collected from the Danish Register of Causes of Death, the Danish National Patient Register, and the Danish Palliative Care Database. Analyses were descriptive and multivariate logistic regression.

SETTING/PARTICIPANTS

Cancer decedents between 2010 and 2013 in the Capital Region of Denmark.

RESULTS

During the study period, 17,246 individuals died of cancer and 33% received specialized palliative care. In the last 14 days of life, 4.2% received chemotherapy. Younger patients and patients with hematological cancers were more likely to receive chemotherapy in the last 14 days of life. Receiving specialized palliative care was associated with a lower risk of receiving chemotherapy in the last 14 days of life-odds ratio 0.15 for hospices and 0.53 for palliative hospital units. A total of 8% of the population received concurrent antineoplastic treatment and specialized palliative care. Female gender, younger age, and breast and prostate cancer were significantly associated with this concurrent model.

CONCLUSION

Overall, the incidence of antineoplastic treatment in the last 14 days of life was low compared to other studies. Patients in specialized palliative care had a reduced risk of receiving chemotherapy at the end of life.

What happens at the end of life? Using linked administrative health data to understand healthcare usage in the last year of life in New Zealand

The end of life is often associated with increased use of healthcare services. This increased use can include over-medicalisation, or over-treatment with interventions designed to cure that are likely futile in people who are dying. This is an issue with medical, ethical, and financial dimensions, and has implications for health policy, funding and the structure of care delivery. We measured the annual use of nine pre-defined public healthcare services between 1 January 2008 and 31 December 2012 by elderly New Zealanders (65-99 years old) in their last year of life and compared it with that of the cohort of elderly New Zealanders who used healthcare in the period but did not die. We used linked, encrypted unique patient identifiers to reorganise and filter records in routinely collected national healthcare utilisation and mortality administrative datasets. We found that, in New Zealand, people do seem to use more of most health services in their last year of life than those of the same age who are not in their last year of life. However, as they advance in age, particularly after the age of 90, this difference diminishes for most measures, although it is still substantial for days spent in hospital as an inpatient, and for pharmaceutical dispensings.

Use of Radiation Therapy Within the Last Year of Life Among Cancer Patients

PURPOSE

We examined radiation therapy (RT) use within the last year of life (LYOL). As palliative RT (PRT) has been well studied in patients with ≥6-week life expectancies, we hypothesized that PRT use would be constant over the LYOL, except for the last 30 days, when use would decline given lack of prospective data supporting it.

MATERIALS AND METHODS

At a single institution, 870 cancer patients died between October 2, 2014, and September 30, 2015, and had ≥3 evaluation and management visits within the LYOL. Claims and RT data were extracted and linked. Over the LYOL, we evaluated RT use by intent (curative vs palliative) and indications.

RESULTS

Within the LYOL, one-third of patients underwent RT in the last 365 days of life to 444 sites, which decreased to 24.3% and 8.5% in the last 180 and 30 days of life, respectively. Patients who received any RT in the last 365 days of life were younger at death and had a higher proportion of lung, sarcoma, and transplant disease groups. One-quarter of sites were irradiated with curative intent, which remained constant over the LYOL. In contrast, PRT was used at a supralinear rate, in which treatment of bone metastases and use of single-fraction PRT increased closer to death.

CONCLUSIONS

PRT appears to be disproportionately used closer to death, with an increasing proportion of irradiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer toward the end of life. As patients with very poor prognoses (eg, within 30 days of death) are generally not included in RT clinical trials, further studies are warranted to assess whether PRT for bone metastases at the end of life is efficacious.

Machine Learning in Radiation Oncology: Opportunities, Requirements, and Needs

Machine learning (ML) has the potential to revolutionize the field of radiation oncology, but there is much work to be done. In this article, we approach the radiotherapy process from a workflow perspective, identifying specific areas where a data-centric approach using ML could improve the quality and efficiency of patient care. We highlight areas where ML has already been used, and identify areas where we should invest additional resources. We believe that this article can serve as a guide for both clinicians and researchers to start discussing issues that must be addressed in a timely manner.

Preventing Discontinuation of Radiation Therapy: Predictive Factors to Improve Patient Selection for Palliative Treatment

PURPOSE

Approximately one third of patients with cancer require palliative radiation therapy (PRT), yet no guidelines exist for optimal patient selection. We have observed that many patients who begin PRT do not complete their prescribed treatment. Our study sought to identify factors associated with discontinuation of PRT, assess for a relationship with survival, and inform patient selection.

METHODS

We performed an institutional review board-approved retrospective analysis of patients with cancer treated in a multicenter radiation oncology department in 2014. Of 297 patients who began PRT, 60 discontinued and 237 completed treatment. Primary end points included discontinuation and overall survival.

RESULTS

Patient factors were analyzed for association with discontinuation of PRT and overall survival, respectively, using logistic regression and Cox proportional regression models. Factors associated with discontinuation were low Karnofsky performance status (KPS) score, high number of fractions prescribed, and treatment site other than bone metastasis. The odds of discontinuing PRT decreased by approximately 52% for every 10-point increase in KPS score (odds ratio, 0.48; 95% CI, 0.36 to 0.63; P < .001). Factors associated with shorter survival included discontinuation of PRT, low KPS score, community practice location, multiple comorbidities, and treatment of brain metastases. Patients who discontinued treatment were more likely to die than patients who completed treatment, independent of other factors (hazard ratio, 3.67; 95% CI, 2.41 to 5.61; P < .001).

CONCLUSION

Patients with low KPS scores, long treatment courses, and those treated to sites other than bone metastasis were significantly more likely to discontinue treatment. Discontinuation was predictive for poor survival. Pretreatment evaluation of KPS, comorbidities, and brain metastases can help guide appropriate patient selection for PRT.

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.

Impact of Radiation Therapy on Aggressive Care and Quality of Life Near Death

CONTEXT

Radiation therapy (RT) is used with palliative intent in patients with advanced stage cancer. Prior studies, primarily in patients with poor performance status (PS), suggest that RT is associated with aggressive medical care, which may impact patients' quality of life near death (QoD) adversely.

OBJECTIVE

This study examines associations between RT use and patients' receipt of aggressive care and QoD based on patients' PS.

METHODS

This is a multi-institutional, prospective cohort study of patients with end-stage cancers (N = 312) who were identified as terminally ill at study enrollment. RT use (n = 24; 7.7%) and Eastern Cooperative Oncology Group (ECOG) PS were assessed at study entry (median = 3.8 months before death). Aggressive care near death was operationalized as use of mechanical ventilation and/or resuscitation in the last week of life. QoD was determined using validated caregiver ratings of patients' physical and mental distress in their final week.

RESULTS

RT use was associated with higher QoD (8/8, 100.0%, vs. 58/114, 50.9%; P = 0.006) among patients with good PS (ECOG = 1), more aggressive care near death (3/9, 33.3%, vs. 6/107, 5.6%; P = 0.020) among patients with moderate PS (ECOG = 2), and lower QoD (1/7, 14.3%, vs. 28/51, 54.9%; P = 0.046) among patients with poor PS (ECOG = 3).

CONCLUSIONS

Targeted use of RT in end-of-life cancer care may benefit patients with good PS, but its use may adversely affect patients with poorer PS. Decisions about RT use in this setting should consider likely end-of-life outcomes based on patients' current PS.

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.

Resource Use in the Last Year of Life Among Patients Who Died With Versus of Prostate Cancer

We conducted a retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data of men with prostate cancer. Among 34,727 patients, those who died of their prostate cancer had more hospice and outpatient use, less inpatient and intensive care unit use, and lower overall costs. Efforts to shift care toward the outpatient setting might provide more efficient and judicious care for patients during the end of life.

BACKGROUND

Prostate cancer poses a significant financial burden in the United States. However, most men with prostate cancer will die from noncancer causes. Concerns about increased resource utilization at the end of life have not been appropriately examined in this context.

MATERIALS AND METHODS

We conducted a retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data of men who were diagnosed with and died of, as opposed to with, prostate cancer between 2000 and 2007. Within these 2 populations, we compared changes in the use of medical interventions, hospice, and overall health care costs to Medicare in the last year of life.

RESULTS

Among 34,727 patients, those who died of prostate cancer had lower costs ($43,572 vs. $45,830; P < .001), largely because of lower mean inpatient costs ($20,769 vs. $29,851) and fewer hospitalizations (1.8 vs. 2.1), inpatient days (12.2 vs. 15.7), intensive care unit (ICU) days (1.4 vs. 3.4), and skilled nursing facility days (11.7 vs. 14.7; P < .001 for all). Outpatient and hospice costs were significantly greater among patients who died of prostate cancer, as was use of chemotherapy and androgen deprivation therapy. Patients who died of prostate cancer had approximately 12% lower costs than patients who died from other causes in adjusted analyses (fold-change, 0.88; 95% confidence interval [CI], 0.85-0.92). The single strongest predictor of increased costs at the end of life was receipt of multiple invasive procedures (fold increase in costs, 2.39; 95% CI, 2.22-2.58).

CONCLUSION

Patients who died of prostate cancer rather than from other causes had more hospice and outpatient use, less inpatient and ICU use, and lower overall costs. Efforts to shift care toward outpatient settings might provide more efficient and judicious care for patients during the end of life.