Improving Quality: Decreasing Radiation Treatment Terminations

Abstract

Treatment terminations (TTs) in radiation oncology can impact the outcomes of patients undergoing curative therapy, as well as the effectiveness of palliative treatments (tx). The causes of TTs are a complex interplay of patient, clinician, and disease factors. There has been little published as to why patients choose, or physicians recommend, TT. As part of ongoing departmental Quality Management, we track these events and seek to understand the causes of TT and opportunities for improvement. We identified 650 unique treatment terminations (TTs) from 6/2013 through 12/2016 within our multi-center department. A TT was defined as the discontinuation of therapy after a virtual simulation (following CT simulation and radiation planning) was scheduled. If a reason for discontinuation was not provided, then a reason was ascertained through chart review. All reasons were categorized into Patient Factors (PF), Clinician Factors (CF), Toxicity Related (TR), Hospice, Death, Disease Progression (DP), or Unknown. Tx intents were categorized into Curative, Palliative, or Benign. Out of 9,100 planned txs, there were 650 TTs representing 7.1% of all txs. Of the TTs, 61% were palliative and 38% curative. The most common reasons for TT was PF (28%) followed by Death (21%) and Hospice (21%). The most common treatment sites for TT were bone (20%) and head and neck (H&N) (19%). 222 txs (34%) were scheduled but received no radiation at the time of discontinuation. Within this group, 59% were palliative and 39% were curative. The most common sites were bone (23%) and H&N (21%). The two most common reasons were PF (36%) and CF (23%). 147 txs (23%) stopped within 25% of the prescribed dose. Of these, 41% were palliative and 59% were curative. The most common site was H&N (27%) followed by CNS (18%) with the two most common reasons being TR (27%) and PF (25%). For patients not receiving a single tx and for those stopping within 25% of the prescribed dose, the combined percentage of hospice/death represent 35% and 28%, respectively. Palliative patients were most likely to discontinue due to death/hospice (58%) and curative patients due to PF (33%). TTs represent a clinical concern not only because the failure to complete a prescribed tx may impact local control, survival, and the effectiveness of treatment, but also because of its impact on patients, families, and health care resources. In our experience, while toxicity and DP play a role, many of the major causes for TTs (PF and CF) within our department can be ascribed in some way to communication at the patient-physician and physician-physician level. Given our data, interventions that may impact this population include thoughtful prognosis discussions, improved patient selection for treatment, and further inclusion of our palliative care colleagues for palliative intent therapy. In the last quarter of treatment, better focus on toxicity management may mitigate these TTs.