Longitudinal Trends in Palliative Radiotherapy, Specialty Palliative Care, and Symptoms Over Time Among Patients With Metastatic Cancer

Abstract

The purpose of this study is to examine longitudinal trends in palliative radiotherapy (RT) and specialty palliative care (PC) among patients with metastatic cancer, determine predictors of earlier PC utilization, and explore distributions of PC symptoms over time. We hypothesize that most palliative RT and specialty PC visits occurred in the last 25% of life remaining from time of diagnosis of metastatic cancer to death.We retrospectively reviewed 162 patients with metastatic cancer who received palliative RT at our institution between 7/2017 and 2/2018; 74 of these patients received specialty PC. Descriptive statistics summarized frequencies of palliative RT consultations, PC visits, and symptoms experienced over time (quartiles 1-3: first 75% vs quartile 4: last 25% of life remaining from metastatic diagnosis to death). We used logistic regression analyses to determine predictors of receiving earlier specialty PC (quartiles 1-3) and Fisher's exact test to examine differences in incidences of hospice referral for earlier (quartiles 1-3) vs later PC (quartile 4).At the time of diagnosis of metastatic cancer, median overall survival among patients receiving specialty PC was 7.0 months (IQR: 4.2-11.6), with the last 25% of life representing a median of 1.75 months. There were 16.2%, 14.9%, 25.5%, and 43.5% of all palliative RT consultations, compared to 9.0%, 11.7%, 16.5%, and 63.8% of all PC visits that occurred in quartiles 1, 2, 3, and 4, respectively. Among the 642 specialty PC visits that occurred, pain was addressed more frequently in quartiles 1-3 (217/559, 38.8%) vs quartile 4 (327/1165, 28.1%), while goals of care and end-of-life symptom management were addressed more frequently in quartile 4 (137/1165, 11.8%) vs quartiles 1-3 (11/559, 2.0%). On multivariable analysis, pain as a presenting PC symptom was a significant independent predictor of receiving earlier PC (OR = 6.41 [95% CI 1.61-34.03], P = 0.015), while patients with receipt of ≥2 prior lines of palliative chemotherapy were less likely to receive earlier PC (OR = 0.20 [95% CI 0.06-0.64], P = 0.009). In a separate regression analysis, both of these variables remained statistically significant after controlling for demographics. There was no statistically significant difference between incidence of hospice referral for those receiving their first specialty PC visit in quartiles 1-3 vs quartile 4 (P = 0.59).Nearly 44% of palliative RT visits compared with 64% of specialty PC visits occurred in the last 25% of life from metastatic diagnosis to death. Patients who reported experiencing pain and those who received ≤1 prior lines of palliative chemotherapy were more likely to have received earlier specialty PC. Identifying factors or symptom triggers that prompt addressing patients' PC needs sooner than the last 2 months of life is needed.