Palliative Radiation Oncology Service Research Articles

Inpatient Simulation Resource Utilization for Inpatient Radiation Oncology Consults

Previous data have shown that inpatient radiation oncology consult services result in high-value care, with decreased length of stay, adoption and delivery of shorter fractionation schedules, and lower hospital costs. As such, institutions are increasingly creating inpatient radiation oncology services, although little is known about the allocation of limited resources for patients who may have limited prognosis, complex simulation requirements, and may have difficulty tolerating treatment. Thus, we sought to examine the utilization of simulation appointments for inpatient emergencies. At our institution, inpatient consults are placed to a specialized inpatient palliative radiation oncology service, consisting of radiation oncologists specialized in metastatic and palliative RT, dedicated advanced practitioners, and nurses who specifically assess patients for medical appropriateness prior to simulation, including changes in disposition, medical stability, and adequate premedication. Electronic health record data was used to explore utilization trends of a single-institution inpatient radiation oncology consult service in 2020. Data regarding the nature and timing of consults, subsequent simulations and treatments, and patient outcomes including 14-day mortality and 30-day mortality from radiation (RT) start were assessed. Descriptive statistics are presented. From 1/1/2020-12/31/2020, 1557 consults were placed. These consults led to 220 (14.1%) inpatient simulations. Of these planned simulations, 210 (95.5%) simulations occurred (of which 10 [4.8%] were rescheduled and eventually completed) and 179 (85.2%) completed treatment. Of 169 with mortality data available, 16 (9.5%) died within 14 days of RT start, and 41 (24.5%) died within 30 days of RT start. Of those with scheduling data (N = 193), 122 were same-day simulations (63.2%), and 507 (93.8%) occurred within 7 days or fewer. Of 1557 inpatient consultations in one year, with appropriate metastatic and palliative experience, only a minority of consultations required inpatient simulation (14.1%). With appropriate nursing assessment, over 95% were able to complete simulation, with nearly two-thirds completing simulation on the same day, and nearly all patients completing simulation within a week of consultation. Most of these patients completed treatment and survived 30 days from treatment start. Thus, with highly specialized radiation oncologist clinical judgment in conjunction with appropriate nursing assessment prior to simulation scheduling, patients booked for simulation represent high-value utilization of resources.

Benefits of Early Identification of Distress in Patients with an Advanced Cancer Diagnosis Receiving Palliative Radiation

Detecting and reducing distress is pivotal in patients with advanced cancer. However, limited data exist on methods of identifying and trending distress in these patients. Additionally, the impact of consultation with a social worker or education regarding end-of-life care on distress is also understudied. In this study, we aimed to analyze if patient reported outcome measures (PROMs) can be used to characterize distress scores and if social work consults can help to reduce distress. We performed a retrospective chart review of 128 patients treated on a palliative radiation oncology service. Patients treated on this service receive PROMs as part of their standard of care and patients rate 13 symptoms including distress, using a Likert 10-point scale. We also assessed whether MOLST education was given at time of consult and whether a social work consult was performed between consult and time of first OTV. We excluded patients who did not receive PROMs at both the time of consultation and first on treatment visit (OTV). The impact of these interventions on distress scores was determined using a comparison of the distress score at time of consultation and the same score at the first OTV. A total of 59 patients were included in this study. Mean age was 65 (Range: 40-86). Primary tumor histologies included lung (27%), breast (10%), prostate (10%) and other (51%). Treated sites included bone (14%), spine (19%), lung (7%) and other (61%). 47% of patients had a social work consultation. 23 patients (39%) reported a distress score > 5 at the time of consultation and 4 patients (7%) reported a distress score of > 10. (Mean: 4; Median: 4; Range: 0-10) Of those patients with distress scores > 5, 30% had lung cancer, 10% had breast cancer, and 10% had prostate cancer. Distress scores were reduced by >=2 points in 17 patients (29%) by the time of their first OTV. 65% of these patients had a social work consultation and 71% had a MOLST discussion at time of consult. This is in comparison to those patients whose scores decreased by <2 points (n=42) where 40% had a social work consult and 71% had a MOLST discussion. PROMS effectively detected increased distress and tracked distress over time. Consultation with a social work at the time of consultation or prior to the first treatment resulted in decrease distress scores in this cohort of patients receiving palliative radiation therapy.

Radiation oncology resident education in palliative care.

Palliative and supportive care education for radiation oncologists in training is essential to deliver comprehensive care to patients. Surveys on palliative care education among radiation oncology program directors and residents demonstrate a disparity in formal teaching and didactics. Integration of formal didactics, communications skills programs, and teaching modules are being piloted at academic centers. A dedicated palliative radiation oncology service has been implemented and the experience evaluated. Future directions to improve resident education in palliative care include improving access and time dedicated to formal didactics, online and interactive modules, rotation in a palliative care service, emphasis on board examinations, and consideration of an advanced palliative care fellowship for radiation oncologists. This is the first review of the available literature reviewing formal palliative education in radiation oncology training programs in the United States.

Impact of a dedicated palliative radiation oncology service on the use of single fraction and hypofractionated radiation therapy among patients with bone metastases.

Radiation therapy (RT) is frequently used to palliate symptomatic bone metastases. While high quality literature has shown that for uncomplicated bone metastases, shorter radiotherapy courses are just as effective as longer courses for the treatment of pain, shorter courses remain under-utilized. We aimed to assess the impact of a dedicated palliative radiation oncology service on the frequency of single fraction RT (SF-RT) and hypofractionated radiation (hypo-RT) (≤5 fractions) among patients with bone metastases. We identified 2,086 instances of palliative radiation (RT) for complicated and uncomplicated bone metastases between April 10, 2008 and September 17, 2014. We used multivariable logistic regression analysis (MVA) to estimate the association of the Supportive and Palliative Radiation Oncology (SPRO) service with the likelihood of receiving SF-RT or hypo-RT after controlling for age, sex, tumor type, and treatment site. Prior to SPRO's implementation on July 1, 2011, the proportion of SF-RT and hypo-RT for bone metastases was 6.4% and 27.6% respectively. After SPRO's implementation, the proportion of SF-RT and hypo-RT increased to 22.3% (P<0.001) and 53.5% (P<0.001) respectively. In MVA, patients were more likely to receive SF-RT [odds ratio (OR) =3.3, 95% confidence interval (CI) =2.4-4.7, P<0.001], and hypo-RT (OR =2.5, 95% CI =2.0-3.1, P<0.001) after SPRO's implementation. Compared to sites without a dedicated palliative service, patients receiving care at the SPRO affiliated department were more likely to receive SF-RT (OR =1.9, 95% CI =1.1-3.2, P=0.02) and hypo-RT (OR =1.5, 95% CI =1.1-2.0, P=0.004) for bone metastases. After SPRO's implementation, the average number of RT courses delivered for bone metastases increased from 17.4 to 25.6 per month, (+8.3, 95% CI =4.99-11.55, P<0.001). Despite greater SF-RT and hypo-RT, the average total fractions per month of palliative RT for bone metastases increased from 163.5 pre-SPRO to 166.8 post-SPRO, though not significantly (+3.22, P=NS). Implementation of a dedicated palliative radiation oncology service was associated with increased use of SF and hypo-RT and with greater courses of RT delivered for bone metastases.

Developing a Palliative Radiation Oncology Service Line: The Integration of Advance Care Planning in Subspecialty Oncologic Care

ABSTRACTWithin radiation oncology, there is often minimal attention on radiotherapy with palliative benefits due to the overlying focus on curative treatments. Historically at the University of Pennsylvania, advanced-stage patients are cared for by cancer site-specific teams rather than a more rapid treatment service model that focuses on patients’ symptom needs and larger clinical issues within a palliative framework. Thus, the University of Pennsylvania created a designated palliative radiation oncology team to focus on the complex medical and relational issues of metastatic cancer patients. Social workers play a critical role in patient and family conversations about advance directives, care needs, and end-of-life goals and fears as treatment regimens and outcomes continue to unfold. The palliative radiation oncology social worker developed and instituted a new, formalized assessment tool called the “palliative radiation oncology psychosocial care plan” in the electronic medical record. A retrospective analysis of 26 palliative radiation oncology patients under treatment between February and August 2016 was conducted. Of these patients treated with palliative radiation, 19% completed an advance directive after the social work intervention. This model highlights advance care planning as a best practice and encourages end-of-life discussions as a routine part of the oncology workflow.

PRADO: A Palliative Care Model for Every Radiation Oncology Practice

During the past few years, large academic radiation oncology programs have uncovered a significant gap in providing palliative care to hospitalized cancer patients. The renowned SPRO (Supportive and Palliative Radiation Oncology) service at Brigham and Women's Hospital ( 1 Tseng Y.D. Krishnan M.S. Jones J.A. et al. Supportive and palliative radiation oncology service: Impact of a dedicated service on palliative cancer care. Pract Radiat Oncol. 2014; 4: 247-253 Google Scholar ) has charted the waters since 2011. Similar programs have begun, including, but not limited to, inPROV (Inpatient Palliative Radiation Oncology Service at Vanderbilt) ( 2 Stavas M.J. Pagan J.D. Varma S. et al. Building a palliative radiation oncology program: From bedside to B.E.D. Pract Radiat Oncol. 2017; 7: 203-208 Google Scholar ) and SOPR (Supportive Oncology and Palliative Radiotherapy at the University of Pennsylvania), which have provided a tremendous benefit to patients, improvements in physician satisfaction, and increases in patient volumes. These academic programs have also incorporated closer follow-up protocols for a subset of patients with metastatic disease, who have a greater risk of requiring additional radiation treatment (RT), such as patients who have received a single fraction of palliative RT (8 Gy × 1) or patients with central nervous system involvement or oligometastatic disease.

Palliative Care Didactic Course for Radiation Oncology Residents

Nearly half of patients who receive radiation therapy are treated by palliative intent ( 1 Tseng Y.D. Krishnan M.S. Jones J.A. et al. Supportive and palliative radiation oncology service: Impact of a dedicated service on palliative cancer care. Pract Radiat Oncol. 2014; 4: 247-253 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar ), and the majority of patients with advanced cancer have physical and psychosocial symptoms that profoundly interfere with quality of life. Palliative care is specialized medical care aimed at relieving symptoms and stress from serious illness, with the goal of improving quality of life, and it is a key part of oncology care ( 2 Bickel K.E. McNiff K. Buss M.K. et al. Defining high-quality palliative care in oncology practice: An American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine guidance statement. J Oncol Pract. 2016; 12: e828-e838 Crossref PubMed Scopus (94) Google Scholar ). During consultation, treatment, and in follow-up, radiation oncologists play an important role in providing primary palliative care, including assessing goals of care to ensure treatments align with patients' wishes, screening for uncontrolled symptoms, discussing prognosis, delivering difficult news, and making referrals to supportive services (such as palliative care and psycho-oncology) ( 3 Quill T.E. Abernethy A.P. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013; 368: 1173-1175 Crossref PubMed Scopus (951) Google Scholar ).

Development and implementation of a clinical pathway for radiation of bone metastases on a palliative radiation oncology service.

170 Background: Clinical pathways increase compliance with treatment guidelines and reduce in-hospital complications. Evidence around treatment of complicated bone metastases is increasingly nuanced and although ASTRO/ACR recommend single fraction radiation therapy for uncomplicated bone metastases, implementation is variable. We sought to determine the effects of a bone metastases-focused clinical pathway on the practice patterns of our institution’s palliative radiation oncology service (SPRO), which sees 600 patients yearly and on a rotating basis, involves 23 physicians, 28 residents, 2 nurse practitioners, and 1 fellow. We hypothesized that pathway implementation would augment data-driven use of palliative radiation for bone metastases, including use of 8 Gy x 1 for uncomplicated metastases. It would also enhance physician efficiency and confidence. Methods: Using published literature, clinical guidelines, and expert input, we designed a comprehensive clinical pathway for bone metastases radiation. This was translated to a secure electronic interface as a decision support tool and integrated into daily SPRO workflows. Providers were surveyed pre and post implementation to assess expectations and elicit feedback. Rates of pathway compliance and reasons for non-compliance were assessed. Rates of 8 Gy x 1 use for uncomplicated metastases were compared pre and post implementation. Our aim was for approximately 70-80% on-pathway rates. Results: The final pathway, which includes twenty endpoints, integrates several validated scoring systems, including assessments of life expectancy, spinal stability, and appropriateness of surgical management. The pathway has been well received on the SPRO service, with addition of extra steps to workflows being the main cause of resistance to use. Data on rates of pathway adherence will be reported, and rates of 8 Gy x 1 use will be compared to the baseline of 22%. Conclusions: Our experience suggests the utility of pathways-based decision support for bone metastases radiation on a palliation consult service. Next steps include assessing the pathway’s effects on guideline-concordant care and calculating associated cost savings.

Acute pain management in radiation oncology: Quality of care and the impact of an integrated palliative oncology service.

195 Background: Radiotherapy (RT) effectively palliates bone metastases, but relief may take weeks, frequently necessitating acute pain management (APM). NCCN Guidelines for Adult Cancer Pain (V2.2015) recommend initiation/titration of analgesics for patients with pain scale value (PSV) ≥ 4. We sought to evaluate how often symptomatic patients have analgesic regimens assessed and intervened upon at radiation oncology (RO) consult for bone metastases, and the impact of a dedicated palliative RO service on APM. Methods: We reviewed consult notes for 217 bone metastases patients treated with RT at Dana Farber Cancer Institute/Brigham &amp; Women’s Hospital (DFCI/BWH) and University of California, San Francisco (UCSF) during June-July 2008, Jan-Feb 2010, Jan-Feb 2013, and June-July 2014, time periods before and after implementation in 2011 of a dedicated palliative RO service at DFCI/BWH. For symptomatic patients, rate of assessment of analgesic regimen was recorded. Among patients with PSV ≥ 4, rate of pain intervention was recorded. The impact of a palliative RO service on these rates was evaluated. Results: Median age was 63 and median KPS was 70. Median PSV for painful bone metastases was 5 (IQR 2-7); 51% had PSV ≥ 4. Among symptomatic patients, analgesic regimen was assessed for 44.5% (51.7% at DFCI/BWH and 28.1% at UCSF). Among patients with PSV ≥ 4, pain intervention occurred for 17.2% (20.5% for DFCI/BWH, 0% for UCSF). At DFCI/BWH, consultation by a dedicated palliative RO provider was associated with higher rate of assessment of analgesic regimen (82.4% vs 47.7%, p = 0.007). At DFCI/BWH, consultation by a palliative RO provider was associated with higher rate of pain intervention (31.2% vs 7.9%, p = 0.012). There was no difference in analgesic regimen assessment or intervention between non-dedicated palliative RO providers at DFCI/BWH and UCSF (p = 0.07 and 0.09, respectively). Conclusions: At two cancer centers, half of bone metastases patients seen for RT have PSV ≥ 4, yet a minority have analgesic assessment and intervention, indicating need for APM quality improvement in RO. An integrated palliative RO service was associated with improved assessment and management of acute pain per NCCN guidelines.

Development and Implementation of a Clinical Pathway for Radiation of Bone Metastases on a Palliative Radiation Oncology Service

170 Background: Clinical pathways increase compliance with treatment guidelines and reduce in-hospital complications. Evidence around treatment of complicated bone metastases is increasingly nuanced and although ASTRO/ACR recommend single fraction radiation therapy for uncomplicated bone metastases, implementation is variable. We sought to determine the effects of a bone metastases-focused clinical pathway on the practice patterns of our institution’s palliative radiation oncology service (SPRO), which sees 600 patients yearly and on a rotating basis, involves 23 physicians, 28 residents, 2 nurse practitioners, and 1 fellow. We hypothesized that pathway implementation would augment data-driven use of palliative radiation for bone metastases, including use of 8 Gy x 1 for uncomplicated metastases. It would also enhance physician efficiency and confidence. Methods: Using published literature, clinical guidelines, and expert input, we designed a comprehensive clinical pathway for bone metastases radiation. T...

Building a palliative radiation oncology program: From bedside to B.E.D

A growing body of evidence supports the integration of palliative care with standard cancer treatments. In these situations, patients often experience a better quality of life, better quality of care, decreased cost, and, in some cases, improved survival with the addition of palliative care services to traditional treatment pathways. In this manuscript, we explore the integration of radiation oncology at palliative care. First, we discuss the impetus for change at Vanderbilt University and the inception of Vanderbilt's inpatient Palliative Radiation Oncology Service at Vanderbilt. Second, we discuss the growth of palliative care and how this invites innovative collaborative care delivery models. As you will see, this mutually beneficial relationship expands new service lines, brings radiation oncology interventions and expertise to more patients seen by palliative care specialists, and improves overall care for some of the sickest, most vulnerable patients in the health care system. As we move away from fee-for-service and toward bundled and global-based strategies, there will be further emphasis on supportive and palliative care services at the end of life. Understanding how radiation oncology can evolve is ever more relevant.

Impact of a Dedicated Palliative Radiation Oncology Service on the Use of Single-Fraction and Hypofractionated Radiation Therapy Among Patients With Bone Metastases

Impact of a Dedicated Palliative Radiation Oncology Service on the Use of Single-Fraction and Hypofractionated Radiation Therapy Among Patients With Bone Metastases

The Supportive and Palliative Radiation Oncology Service: A Dedicated Model for Palliative Radiation Oncology Care

The Supportive and Palliative Radiation Oncology Service: A Dedicated Model for Palliative Radiation Oncology Care

Supportive and palliative radiation oncology service: Impact of a dedicated service on palliative cancer care

PurposeThe American Society of Clinical Oncology has recommended tailoring palliative cancer care (PCC) to the distinct and complex needs of advanced cancer patients. The Supportive and Palliative Radiation Oncology (SPRO) service was initiated July 2011 to provide dedicated palliative radiation oncology (RO) care to cancer patients. We used care providers’ ratings to assess SPRO’s impact on the quality of PCC and compared perceptions of PCC delivery among physicians practicing with and without a dedicated palliative RO service. Methods and materialsAn online survey was sent to 117 RO care providers working at 4 Boston-area academic centers. Physicians and nurses at the SPRO-affiliated center rated the impact of the SPRO service on 8 PCC quality measures (7-point scale, “very unfavorably” to “very favorably”). Physicians at all sites rated their department’s performance on 10 measures of PCC (7-point scale, “very poorly” to “very well”). ResultsAmong 102 RO care providers who responded (response rate, 89% for physicians; 83% for nurses), large majorities believed that SPRO improved the following PCC quality measures: overall quality of care (physician/nurse, 98%/92%); communication with patients and families (95%/96%); staff experience (93%/84%); time spent on technical aspects of PCC (eg, reviewing imaging) (88%/56%); appropriateness of treatment recommendations (85%/84%); appropriateness of dose/fractionation (78%/60%); and patient follow-up (64%/68%). Compared with physicians practicing in departments without a dedicated palliative RO service, physicians at the SPRO-affiliated department rated the overall quality of their department’s PCC more highly (P = .02). ConclusionsClinicians indicated that SPRO improved the quality of PCC. Physicians practicing within this dedicated service rated their department’s overall PCC quality higher than physicians practicing at academic centers without a dedicated service. These findings point to dedicated palliative RO services as a promising means of improving PCC quality.

The Supportive and Palliative Radiation Oncology Service: The Impact of a Dedicated Service on Palliative Cancer Care

The Supportive and Palliative Radiation Oncology Service: The Impact of a Dedicated Service on Palliative Cancer Care

Rapid Response Radiation Therapist: An Expanding Role in the Palliative Radiation Oncology Service in Australia

Rapid Response Radiation Therapist: An Expanding Role in the Palliative Radiation Oncology Service in Australia