Palliative Radiation Therapy Near the End of Life in Lung Cancer Patients: A Population-Based Analysis

Abstract

Palliative radiotherapy (PRT) can improve quality of life for patients with advanced lung cancer, but symptomatic relief may take up to a few weeks. PRT in the last 4 weeks of life is an emerging indicator of poor quality care. We sought to determine the patterns of PRT utilization in patients with advanced lung cancer in a population-based health care system. All patients with lung cancer in a Canadian province treated with PRT between 1st January 2014 and 31st December 2015 were identified. Patient and treatment characteristics were extracted from a provincial cancer database. Chart review was performed for patients receiving potentially radical dose fractionation schedules to confirm palliative intent. Site of PRT was classified as bone, brain or chest; all other sites were excluded. Patients who received more than one course of PRT were considered independently for each course. Associations between starting a course of PRT within 4 weeks of death and patient/treatment characteristics were assessed using chi-square and t-tests. Multi-variable logistic regression analysis was subsequently performed to assess associations. A total of 4,160 courses of PRT were delivered to 2571 patients. Median survival for the entire cohort was 17 weeks (95% CI 15.7-17.4) from start of PRT. Forty-one percent of PRT courses were delivered to chest, 39% to bone and 20% to brain. Fourteen percent of PRT courses were prescribed to patients in the last 4 weeks of their life, with significant differences by male vs female (17% vs 11%; p<0.001), performance status (ECOG 0, 1, 2, 3 and 4 were 8%, 9%, 11%, 19% and 39% respectively; p<0.001), histology (adenocarcinoma, squamous cell carcinoma, NSCLC NOS and small cell lung cancer were 11%, 15%, 19% and 16% respectively; p<0.001) and site of PRT (bone, chest and brain were 17%, 12% and 11%; p<0.001). These associations persisted on multi-variable analysis. Of PRT courses delivered in the last 4 weeks of life, the majority were planned using simple techniques (1-2 fields, 96%) and using short fractionation regimes (single fraction for bone, 71%; ≤5 fractions for brain, 92%; ≤5 fractions for chest, 91%). This population-based analysis found that 14% of PRT courses for lung cancer were delivered in the last 4 weeks of life. Males, those with poor performance status, non-adenocarcinoma histology and bone metastases were more likely to receive PRT near end of life. Appropriately, simple planning techniques and shorter fractionation regimes were used more commonly closer to death. Although there is no consensus of what constitutes poor quality care with regard to PRT near end of life, the limited number of published series report 10-20% death within 4 weeks of PRT. While further clarification in this domain occurs, clinicians should be cognizant of the prognosis of their patients when considering indications and fractionation schedules of PRT.