Radiation Oncology Consultation Research Articles

A Palliative Radiation Oncology Consult Service's Impact on Care of Advanced Cancer Patients.

Palliative radiation therapy (PRT) is a commonly utilized intervention for symptom palliation among patients with metastatic cancer, yet it is under-recognized as a distinct area of subspecialty within radiation oncology. We developed a multidisciplinary service model within radiation oncology called the Palliative Radiation Oncology Consult (PROC) service to improve the quality of cancer care for advanced cancer patients. We assessed the service's impact on patient-related and healthcare utilization outcomes. Patients were included in this observational cohort study if they received PRT at a single tertiary care hospital between 2009 and 2017. We compared outcomes of patients treated after (post-intervention group) to those treated before (control group) PROC's establishment using unadjusted and propensity score adjusted analyses. Of the 450 patients in the cohort, 154 receive PRT pre- and 296 after PROC's establishment. In comparison to patients treated pre-PROC, post-PROC patients were more likely to undergo single-fraction radiation (RR: 7.74, 95% CI: 3.84-15.57) and hypofraction (2-5 fraction) radiation (RR: 10.74, 95% CI: 5.82-19.83), require shorter hospital stays (21 vs. 26.5 median days, p = 0.01), and receive more timely specialty-level palliative care (OR: 2.65, 95% CI: 1.56-4.49). Despite shortened treatments, symptom relief was similar (OR: 1.35, 95% CI: 0.80-2.28). The PROC service was associated with more efficient radiation courses, substantially reduced hospital length of stays, and more timely palliative care consultation, without compromising symptom improvements. These results suggest that a multidisciplinary care delivery model can lead to enhanced quality of care for advanced cancer patients.

Propensity score matched analysis of a palliative radiation oncology consult service’s impact on length of stay and total costs during hospitalization.

162 Background: The Palliative Radiation Oncology Consult Service (PROC) was a clinical service model developed in 2013 at Mount Sinai Hospital to provide individualized, goal-directed treatment to advanced cancer patients requiring palliative radiation therapy (PRT). We assessed its impact on length of stay (LOS) and total costs incurred during a hospitalization among patients who underwent PRT for symptomatic bone metastases while in the hospital. Methods: In our observational cohort study, we identified patients who underwent their first PRT course for bone metastases during a hospitalization between 2/2010 and 12/2016. Total costs (direct and indirect costs) during the hospitalization were extracted from the institution’s cost accounting system. Propensity score matching (PSM) was performed against age, Charlson comorbidity index (CCI), gender, race, primary cancer, and health insurance status. Balance across groups was verified by standardized differences before and after PSM. Average treatment effects (ATE) of hospital costs and LOS were calculated from generalized linear models with a γ distribution and log link adjusted by propensity score weights. PRT patients treated before 2013 (before PROC was established) were compared to those treated after 2013 (after PROC was established). Results: In total, 181 patients were included, with 76 treated before and 105 treated after PROC. Before propensity score matching, patients treated prior to PROC’s establishment had a median total hospital cost of $72,787 (range, $5,981-$324,652) and a median LOS of 28 days (range, 2-105); whereas patients treated after PROC had a median total hospital cost of $49,950 ($7,585-$620,943) and a median LOS of 19 days (2-139). After matching, patients had an ATE of -$16,877 total hospital cost (95% CI [-33,250,-504], p = 0.043) and -8.5 days in LOS (95% CI [-13.9,-3.2], p = 0.002). Conclusions: PROC, a clinical service model that integrated principles of palliative care practice within radiation delivery, led to substantial cost-savings and shorter lengths of stay for advanced cancer patients requiring PRT for bone metastases during a hospitalization.

Characteristics of urgent palliative cancer care consultations encountered by radiation oncologists.

135 Background: Palliative radiation therapy(PRT)is often employed in patients with advanced cancers requiring urgent consultation given the rapidity of presentation.We report on characteristics of urgent palliative oncologic issues encountered by radiation oncologists(RO). Methods: We prospectively evaluated patterns of presentation in162 consecutive consultations for urgent PRT at 3 centers from 5/19/14 to 9/26/14.Survey of palliative care issues was completed by physicians/nurse practitioners including assessment of reasons for urgent radiation oncology consultation,disease presentation characteristics and site of RT delivery.Response rate was 86% with 140 of 162 responses received. Results: Median age of patients was 63 years(29-89)with 39% > 65, 41% from 50-65 and 20% < 50 years;56% were males and 44% females. Most were married(62%)and 30% non-Caucasians.48% had ECOG PS 0-1,whereas it was 2, 3 and 4 in 24%,9% and 3%.Primary cancer diagnoses were lung (28%),breast(13%),prostate(10%),melanoma(10%),sarcoma(7%) and other diagnoses in 32%.Pain was predominant reason for consult(57%)followed by brain metastases(29%),spinal cord/cauda compression (13%),dyspnea (10%),bleeding (8%),bone fracture(4%)and dysphagia(2%).Clinicians managed pain (69%),neurologic symptoms(51%),fatigue (49%),intestinal(21%),respiratory (19%) symptoms,bleeding (14%),insomnia (13%),nausea/vomiting(12%)and dysphagia(6%).Patients presented at all stages 79% at the time of their diagnosis of metastatic cancer,63% with an established ( > 1 month) metastatic cancer diagnosis and continuing to further cancer therapies and 17% proceeding to hospice care without further anti-cancer therapy after PRT. Conclusions: Radiation oncologists care for patients across time course of metastatic cancer diagnosis managing variety of urgent oncologic issues,most commonly metastases causing pain followed by brain metastases and cord compression.They also manage cancer-related symptoms,mostly pain,neurological symptoms and fatigue.These findings point to need for palliative care to be well integrated into radiation oncology practice including education and systems of care.

Predictors of Placement of Inpatient Palliative Care Consult Orders Among Patients With Breast, Lung, and Colon Cancer in a Safety Net Hospital System.

The provision of palliative and end-of-life care to patients who are underrepresented and underserved provides unique challenges and opportunities. To examine predictors of placement of inpatient palliative care consult orders among patients with breast, lung, and colorectal cancer hospitalized in a safety net hospital in 2010. Simple and multivariable logistic regression of data on selected patients with cancer was performed to identify predictors of placement of inpatient palliative care consult orders. Of 979 patients, 56% had colorectal cancer, 23% had lung cancer, and 21% had breast cancer. Of those patients, 16% received an order for inpatient palliative care consultation during the study period. Patients who had more than 20 prescriptions for opioids ordered (adjusted odds ratio [AOR]: 9.10, 95% confidence interval [CI]: 4.62-17.95), had an order for a radiation oncology consult (AOR: 2.60, 95% CI: 1.50-4.49), or had low albumin (AOR: 2.75, 95% CI: 4.71) were more likely to have an order for an inpatient palliative care consult placed. Race and ethnicity were not statistically significant predictors. In this cohort of patients in a safety net hospital, markers of pain, advanced disease, and poor prognosis were associated with placement of inpatient palliative care consult orders.

“Calibrating” the Distress Thermometer: Demographic and Clinical Determinants of Reported Distress Among Patients Presenting for Radiation Oncology Consultation

Cancer patients are known to experience high levels of various forms of psychosocial distress, which can be heightened during periods of transition or uncertainty. Initiation of radiation therapy can be a distressing experience for many patients. The NCCN currently recommends screening all cancer patients for distress using a thermometer (scoring 0-10) and questionnaire to identify patients who may benefit from referral to social work or mental health resources. This study aims to determine clinical and nonclinical factors that are associated with higher levels of patient distress and demographic differences in distress reporting to help inform better identification and treatment of distress in the radiation oncology patient population. An IRB approved retrospective analysis was conducted following a one year period of accrual of completed distress screening forms from 129 patients upon their initial consultation by one institution's Department of Radiation Oncology. Clinical data, including cancer site/stage, and demographic data, including race, age, and gender, were linked with the distress data. Both univariate and multivariate analyses were conducted to clarify the relationships between these clinical and non-clinical factors on measures of patient distress. Cancer stage was positively associated with distress scores. On average, each increase in stage added 0.80 points to one’s distress score (p<0.05). Patients with skin cancer had higher levels of distress than those with cancers of other sites (p<0.05). Among specific questionnaire items, feelings of sadness, fear/worry, or depression and concerns about pain were the most predictive of higher distress scores. Among these, feeling fear/worry had an 82% sensitivity (95% CI 59-94) and 71% specificity (95% CI 59-81) for a distress score of 7 or greater. Gender, age, and race were not associated with distress scores. Compared to Caucasians, African Americans had a higher prevalence of concerns about finances/insurance, transportation, work/school, and spirituality/religion, independent of distress score. Notably, 54% African Americans reported having concerns about finances/insurance, compared to 16% of Caucasians (p<0.0001). Patient reported distress scores are associated with cancer site and stage and specific emotional and physical factors, and race is associated with key differences in reported components of distress. Increased awareness of how the specific factors identified are associated with distress levels can allow social support services to be better tailored to the individual needs of the radiation oncology patient. Further, this analysis can help develop criteria other than a numerical distress score cutoff to be used as a trigger for referrals to social support services.

Prostate clinical outlook visualization for patients and clinicians considering cyberknife treatment: A personalized approach.

e16549 Background: When a patient presents with localized prostate cancer, referral for radiation oncology consultation includes a discussion of likely outcomes of therapy. Among current radiation treatments for prostate cancers, hypo-fractionated stereotactic body radiation therapy (SBRT) has gained clinical acceptance based on efficacy, short duration of treatment and potential radiobiological advantages. The prostate Clinical Outlook (PCO) visualization system was developed to provide the patient and the clinician with a tool to visualize probable treatment outcomes using institutional, patient specific data for comparing results of treatment. Methods: We calculated the prostate cancer outlooks for each prospective patient using the EPIC-26 quality of life parameters based on clinical outcomes data of 580 cyberknife SBRT treated prostate cancer patients. We applied Kaplan-Meier analysis using the ASTRO method for disease free likely outcome and the PCO nomogram to calculate parameters for quality of life. Open source R, R/Shiny, and MySQL were used to develop a modularized architecture system. Results: PCO presents patient specific risk scores in a gauge chart style and risk free probability bar plots to compare treatment data of cyberknife patients. PCO generates reports, in PDF and HTML, which consist of a comparison chart of risk free probabilities and gauge charts of risk scores. This system is now being expanded as a web-based service to patients. Conclusions: PCO visualized patient specific likely outcomes were compared to treatment data from a single department, helping the patient and the clinician to visualize likely outcomes. The PCO approach can be expanded to other specialties of oncology with the flexible, modularized architecture which can be customized by changing parameter variables for the modules.

Adjuvant Radiotherapy Use by US Radiation Oncologists After Radical Cystectomy for Muscle-invasive Bladder Cancer

AimsHistoric trials suggested significant toxicity with adjuvant radiotherapy (ART) after radical cystectomy for muscle-invasive bladder cancer (MIBC). However, recent trials have found improved locoregional control and the 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ART consideration for select patients at high risk of local recurrence. ART practice patterns among US radiation oncologists are unknown and we carried out a survey to explore current trends. Materials and methodsWe conducted a survey of US radiation oncologists regarding the management of patients with cT2-3N0M0 transitional cell MIBC. Responses were reported using descriptive statistics. Chi-square and univariate logistic regression of clinical and demographic covariates were conducted, followed by multivariable logistic regression analysis to identify factors predicting for ART use. ResultsIn total, 277 radiation oncologists completed our survey. Nearly half (46%) have used ART for MIBC at least once in the past. In ART users, indications for ART include gross residual disease (93%), positive margins (92%), pathological nodal involvement (64%), pT3 or T4 disease (46%), lymphovascular invasion (16%) and high-grade disease (13%). On univariate logistic regression, ART use was associated with the number of years in practice (P=0.04), pre-cystectomy radiation oncology consultation (P=0.004), primarily treating MIBC patients fit for cystectomy (P=0.01) and intensity-modulated radiotherapy use (P=0.01). On multivariable logistic regression analysis, routine pre-cystectomy radiation oncology consultation (odds ratio 1.91, 95% confidence interval 1.04–3.51; P=0.04) and intensity-modulated radiotherapy use (odds ratio 2.77, 95% confidence interval 1.48–5.22; P=0.002) remained associated with ART use. ConclusionsART use is controversial in bladder cancer, yet unexpectedly has commonly been used among US radiation oncologists treating patients with MIBC after radical cystectomy. NRG-GU001 was a randomised trial in the US randomizing patients with high-risk pathological findings for observation or ART after cystectomy. However, due to poor accrual it recently closed and thus it will be up to other international trials to clarify the role of ART and identify patients benefiting form this adjuvant therapy.

Does ultrasound measurement improve the accuracy of electronic brachytherapy in the treatment of superficial non-melanomatous skin cancer?

PurposeElectronic brachytherapy (eBT) is a form of contact radiation therapy used for thin superficial non-melanomatous skin cancers (NMSCs). An accurate measurement of diameter and depth is important for eBT treatment planning. Therefore, we compared clinical measurements by an experienced physician to measurements obtained using ultrasound (US), an objective imaging modality, in order to determine if clinical measurements were accurate enough for adequate NMSC treatment.Material and methodsEighteen patients with 20 biopsy-proven NMSCs first had a clinical examination and then an US evaluation prior to starting eBT. One physician provided a clinical measurement for diameter and depth based on physical examination during radiation oncology consultation. The patients then had an US evaluation with a 14 or 18 MHz US unit, to determine both the diameter and depth measurements; eBT dose prescription was done using the US derived measurements. The clinical measurements and US measurements were compared using a t-test.ResultsSeventeen lesions were basal cell carcinoma and 3 lesions were squamous cell carcinoma. The most common location was the nose (10 lesions). The difference between the clinical and the US derived measurements for the second largest diameter was found to be statistically significant (p = 0.03), while the difference for the largest diameter of the lesions was not (p = 0.24). More importantly, the depth measurements obtained with US were also found to be significantly different from the clinical estimates (p = 0.02). All patients have had a complete response to therapy with a median follow-up of 24 months.ConclusionsStatistically different measurements were obtained in 2 of 3 parameters used in choosing applicator size and prescription depth using an US assessment. The data presented suggests that US is a more objective modality than clinical judgment for determining superficial NMSC diameter and prescription depth for personalized eBT planning.

Patterns of Referral to Radiation Oncology among Patients with Bladder Cancer: a Population-based Study

AimsRadical radiotherapy is a reasonable alternative to cystectomy for some patients with invasive bladder cancer, and postoperative radiotherapy may be indicated in patients at high risk of local recurrence. Here we describe pre- and postoperative radiation oncology consultation among patients with bladder cancer in Ontario. Materials and methodsRecords of radiotherapy and surgery were linked to the Ontario Cancer Registry (OCR) to identify all patients who received treatment with curative intent for bladder cancer between 1994 and 2008. Billing records were linked to the OCR to determine which patients were seen by radiation oncology before radical therapy or after cystectomy. Factors associated with radiation oncology consultation were explored by logistic regression. ResultsIn total, 5259 patients with bladder cancer underwent treatment with curative intent in Ontario between 1994 and 2008. Of these, 3879 had primary cystectomy and 1380 had primary radiotherapy. Thirty-two per cent (1698/5259) of all patients were seen by radiation oncology. Independent factors associated with radiation oncology consultation included advanced age (P < 0.001), greater comorbidity (P < 0.001) and earlier year of diagnosis (P < 0.001). Rates also varied widely across geographical regions (range 20–57%); this variation was highly significant on multivariate analysis (P < 0.001). Only 10% (370/3759) of patients with cystectomy had a preoperative radiation oncology consultation. Ten per cent of patients treated by cystectomy (386/3879) were seen by radiation oncology in the postoperative setting; rates varied widely across regions (range 6–44%). These geographical variations were highly significant in the multivariate analysis (P < 0.001), which also showed that younger patients, those with higher stage (pT or pN), and those with positive margins, were more likely to have a postoperative radiation oncology consultation (all P < 0.001). Only 19% (80/420) of cases with positive margins had a postoperative radiation oncology consultation. ConclusionsOne third of all patients with muscle-invasive bladder cancer in routine practice were seen in consultation by radiation oncology. Few patients who undergo cystectomy have the benefit of either a preoperative or a postoperative opinion about the potential role of radiotherapy in their management. Closer collaboration between radiation oncologists and urologists is warranted.

Pain Assessment at Radiation Oncology Consultation for Bone Metastases

Pain Assessment at Radiation Oncology Consultation for Bone Metastases

CAN.recall

CAN.recall is a new app designed to help patients ask questions and retain the information given to them at their surgical, medical, and radiation oncology consultations. The app combines a clinically developed question prompt list (QPL) organised into categories that follow the general evolution of consultation discussions, with flexibility to edit the list to suit the patient's circumstances. It also contains a sound recording function that allows you to replay the doctor's response.

Implementation of a Lung Cancer Nurse Navigator Enhances Patient Care and Delivery of Systemic Therapy at the British Columbia Cancer Agency, Vancouver.

A nurse navigator (NN) pilot project for patients with lung cancer was implemented in British Columbia, a publicly funded health-care system. The purpose was to improve referral practices, timelines, and availability of molecular testing for patients with advanced non-small-cell lung cancer (NSCLC). Patients with stage IIIB/IV NSCLC referred to the BC Cancer Agency, Vancouver, in 2011 and 2014, pre- and post-implementation of an NN, were included. Referral patterns, systemic therapy, radiotherapy (XRT) timelines, and molecular testing practices were compared. The study included 408 patients: 212 in 2011 and 196 in 2014. Medical oncology (MO) end points comparing 2011 data with 2014 findings revealed that referral rates remained stable, and the proportion of patients who received systemic therapy increased from 57% to 69% (P = .05). Time from referral to MO consult was 18 days in 2011 versus 15.5 days in 2014 (P = .11); referral to systemic treatment was reduced from 48 to 38 days (P = .016). Comparison of molecular testing showed time between referral and the epidermal growth factor (EGFR) result was reduced from 34 days in 2011 to 20 days in 2014 (P < .001); rates of testing increased from 62% to 91%, respectively (P < .001); and EGFR mutation-positive rates were 19% versus 26%, respectively (P = .26). The radiation oncology (RO) end point results were as follows: 87% of patients were referred for RO consults in 2011 versus 80% in 2014 (P = .05), and the same proportion of patients received XRT (91% v 87%, respectively). Time from referral to RO consult decreased from 10 days in 2011 to 8 days in 2014 (P = .005); and referral to XRT in 2011 and 2014 was 18 days versus 11.5 days, respectively (P < .001). Implementation of an NN was associated with reduced wait times and increased molecular testing, improving appropriate delivery of first-line targeted therapy. NN involvement facilitates correct allocation of physician and clinical resources.

Role of Dose on Survival in Adjuvant Chemoradiation Pancreatic Cancer

Purpose/Objective(s): ACEi and ARB are commonly prescribed medications in the management of hypertension and diabetes. Pre-clinical and clinical data has suggested mitigating effects of these drugs on radiationinduced lung injury, which has implications for thoracic radiation therapy (RT). Whether ACEi/ARBs have a negative effect on tumor response still needs to be elucidated. In this study, we examined the correlation between ACEi/ARB and incidence of pCR as a surrogate for anti-tumor effect in patients receiving trimodality therapy for esophageal cancer. Materials/Methods: Between March 2000 and July 2012 135 patients with esophageal cancer were treated with NA-CRT followed by esophagectomy at our institution. The median age at diagnosis was 59 years (range, 26-82). The cohort was dominated by male patients (86%), distal esophageal primary (89%) and adenocarcinoma histology (76%). Predominant stage distribution was stage III (47%) and stage II (36%). Median radiation dose was 50.4 Gy (range 45.0-56.4Gy). Most common concurrent chemotherapy regimen was Cisplatin/5-Fu (59%). Primary endpoint was pCR rates with secondary endpoints of overall survival (OS) and progression free survival (PFS). Chi-square analysis along with univariate and multivariate Kaplan-Meier and Cox Regression analysis were performed. Results: With a median follow-up of 2.1 years, estimated median OS and PFS for the entire cohort were 2.7 years (95% CI: 2.0-3.4) and 2.8 years (95% CI: 1.9-3.7). 45 patients (33%) were taking ACEi/ARB at the time of radiation oncology consultation compared to 90 (67%) patients not taking ARBs. There were no significant differences in the distribution of key baseline variables between the two groups. The pCR rates with and without ACEi/ARB use were 36% and 43%, respectively (pZ0.39). Median OS and PFS in this group were 2.4 and 1.7 years, respectively. 3-year OS with and without ACEi/ARB use was 38.1% and 47.2% respectively, pZ0.2. Similarly, 3-year PFS was 42.9% and 47.6% respectively, pZ0.94. On multivariate analysis including use of ACEi/ARB in the model, none of the baseline characteristics impacted OS (borderline significance for N-stage, p < 0.1) and only advanced nodal status was associated with worse PFS (HRZ1.9, 95% CI 1.1-3.3, pZ0.03) with borderline significance of anatomical location and gender (p < 0.1). Conclusion: In our study, the use of ACEi/ARB was not associated with inferior pCR rates, OS or PFS. Validation in larger prospective databases with longer follow up is necessary to assess confounding effect of associated medical comorbidities on survival. If validated, then this absence of a negative impact supports their development as mitigators of radiation induced lung injury. Author Disclosure: J. Hyder: None. H. Boggs: None. M.D. Chuong: None. M. Suntharalingam: None. W. Burrows: None. N. Horiba: None. D.P. Zandberg: None. T.N. Tyer: None. E.P. Cohen: Research Grant; Department of Veterans Affairs. review of policy, planning meeting; Cancer and Kidney International Network. Z. Vujaskovic: None. P. Mohindra: None.

A palliative radiation oncology consult service’s impact on care of advanced cancer patients with symptomatic bone metastases.

110 Background: Single-fraction and ≤ 5 fraction radiation treatment (SF-RT and Hypo-RT, respectively) is underutilized despite strong evidence regarding its efficacy in symptom management. Established in 2013, the Palliative Radiation Oncology Consult Service (PROC) is a specialty service designed to provide individualized, efficient treatment for advanced cancer patients by a radiation oncology team with a dedicated palliative care focus. We assessed the impact of this new model of care on use of SF-RT, hypo-RT, pain improvement, palliative care utilization, and hospitalization among patients treated with palliative radiation (PRT) for painful bone metastases. Methods: We searched electronic charts of advanced cancer patients who had PRT for symptomatic bone mets from Dec 2010 to April 2015, extracting PRT details, demographics, cancer type, pain pre- and 1 month post-PRT, comorbidities (summarized using Charlson comorbidity index [CCI]), palliative care consults, and hospitalization. Comparisons were made before and after PROC using chi-square or t-tests. Multivariable logistic regression estimated the likelihood of SF-RT or hypo-RT, controlling for age, gender, cancer type, treatment site, and CCI. Results: We identified 334 patients, described in the table below. Patients were more likely to have SF-RT (OR 2.2, 95% CI [1.2-3.8], p = 0.007), or hypo-RT (OR 3.0, 95% CI [1.8-4.7], p &lt; 0.001) after establishment of PROC. Conclusions: Establishment of a PROC service nearly doubled utilization of SF-RT and hypo-RT while maintaining pain improvement, and was associated with an increased use of palliative care consult services, decreased inpatient PRT use, and decreased length of stay. A dedicated service combining palliative care principles and radiation oncology improved quality of palliative cancer care. [Table: see text]

The patient's perspective on stereotactic body radiation therapy (SBRT) vs. surgery for treatment of early stage non-small cell lung cancer (NSCLC)

We investigated the patient's perspective on SBRT for treatment of stage I NSCLC and compared the patient's perspective of SBRT to that of surgery. IRB approval was obtained to contact patients who had received SBRT for stage I NSCLCs. Patients were asked questions inquiring into their knowledge of SBRT and how their SBRT experience compared to their original expectations. Patients who had undergone prior surgery for a previously diagnosed stage I NSCLC were asked questions comparing their experience between SBRT and surgery. Frequencies of these reported measures were calculated and analysis was done using Fisher's exact test. 102 patients were contacted with 91 (89%) participating. Among all patients, prior to their radiation oncology consultation, 56% had no knowledge of SBRT and 58% believed SBRT to be as effective as resection. After consultation, 98.9% did not believe they were getting an inferior treatment with SBRT. 92.3% of patients reported less side effects, 59.3% reported SBRT to be more convenient and 87.9% reported SBRT to be less anxiety provoking than compared to their original expectations. Among patients with prior lung surgery (N=39), compared to surgery, 100% reported an easier recovery, less treatment related anxiety and less caregiver strain with SBRT. Overall, 79.5% were more satisfied with SBRT than surgery and 89.7% would have rather had SBRT than surgery as it was performed for their prior NSCLC. Actual experiences with SBRT are overwhelmingly superior compared to patient expectations. Patients with prior lung surgery reported significantly more satisfaction with SBRT.

Cancer screening patterns in caregivers accompanying patients to radiation oncology.

e12567 Background: To explore cancer screening habits of caregivers, defined in this IRB-approved study as individuals accompanying patients to radiation oncology consultations. Our objectives were...

Access to oncology consultation in a cancer cohort in northeastern Ontario.

To enhance cancer symptom management for residents of Sudbury-Manitoulin District, an ambulatory palliative clinic (pac) was established at the Northeast Cancer Centre of Health Sciences North. The pac is accessed from a medical or radiation oncology consultation. The primary purpose of the present population-based retrospective study was to estimate the percentage of cancer patients who died without ever having a medical or radiation oncology consultation. A secondary purpose was to determine factors associated with never having received one of those specialized consultations. Administrative data was obtained through the Ontario Cancer Data Linkage Project. For each index case, we constructed a timeline, in days, of all Ontario Health Insurance Plan billing codes and associated service dates starting with the primary cancer diagnosis and ending with death. Within the 5-year study period (2004-2008), 6683 people in the area of interest with a valid record of primary cancer diagnosis died from any cause. Most (n = 5988, 89.6%) had 1 primary cancer diagnosis. For that subgroup, excluding those with a disease duration of 0 days (n = 67), about 18.4% (n = 1088) never had a consultation with a medical or radiation oncologist throughout their disease trajectory. Patients who were older or who resided in a rural area were significantly less likely to have had a consultation. Specific strategies directed toward older and rural patients might help to address this important access-to-care issue.

Statin use in cancer patients with brain metastases: a missed communication opportunity at the end of life.

Preventive care, referring to medical interventions with anticipated long-term benefits, is often inappropriately continued near the end of life. We examined the use of statin medications in patients with brain metastases receiving whole brain radiation therapy to determine the effect of short life expectancy and regular interaction with oncology providers on statin discontinuation. We propose reasons for the unnecessary continuation of preventive care and suggest that it is a frequently missed communication opportunity to discuss prognosis in a concrete manner. This is a retrospective study examining statin use in patients receiving whole brain radiotherapy for brain metastases. A total of 206 patients at two cancer centers were studied, and information on statin use and clinical characteristics was obtained from review of the medical record. Of the 206 patients, 53 (26 %) were on a statin at their initial radiation oncology consultation. Of these patients, 13 (25 %) had their statin discontinued by the time of their last follow-up visit, but 40 patients (75 %) were continued on their statin despite their limited life expectancy and low likelihood of benefit. The majority of patients who were on statins prior to starting palliative whole brain radiation therapy remained on a statin after completing treatment despite an estimated survival of months and regular visits with an oncologist. This represents a missed opportunity for doctors and patients to discuss the appropriateness of continuing preventive care as part of an important conversation about prognosis.

Abstract 4141: Access to medical or radiation oncology consultation in patients who died from cancer in the Sudbury-Manitoulin District of Northeastern Ontario, Canada

Abstract Sudbury-Manitoulin district is located in Northeastern Ontario, Canada, and resident cancer patients often receive care at the Northeast Cancer Centre (NECC), a Cancer Care Ontario regional cancer program located at Health Sciences North in Sudbury. In 2008, as part of enhancing services in this district, the NECC established an ambulatory Palliative Clinic. Presently, referral to this clinic occurs subsequent to a patient consultation with a medical or radiation oncology specialist. Using administrative data, the primary purpose of this population-based retrospective study was to estimate the percentage of patients who died from cancer without having had the opportunity to access this clinic through a prior documented medical or radiation oncology consultation during the interval of 2004-2008. A secondary purpose was to determine factors associated with never having received this specialized medical consult. Data was obtained through The Ontario Cancer Data Linkage Project (`cd-link') an initiative of the Ontario Institute for Cancer Research/Cancer Care Ontario Health Services Research Program. For each index case, we constructed a timeline (days) of all Ontario Health Insurance Plan (OHIP) billing codes and associated service dates, from primary cancer diagnosis through to cancer death. Our main outcome variable, consultation with a medical or radiation oncologist, was dichotomized as “ever” or “never”. A total of 6,683 individuals with a valid primary cancer diagnosis record died from any cancer cause in the Sudbury-Manitoulin District within the 5 year period from 2004-2008. Most (n=5988, 89.6%) had one primary cancer diagnoses. For this subgroup, and excluding those with a disease duration of 0 days (n=67), about 18.4% (n=1088/5921) never consulted a medical or radiation oncologist through their disease trajectory. Multivariable logistic regression identified three significant and independent predictors of having never received a consultation. Older age and rural residence were associated with increased risk of “never consultation”, with adjusted Odds Ratio (OR)s of 7.13 (95% Confidence Interval (CI) 3.68-13.81) and 1.77 (95% CI 1.51-2.06) for residents 80 years and older, or living in a rural residence, respectively. A longer duration of disease was associated with a decreased risk, with an OR of 0.99 (95% CI 0.99-0.99). While there are limitations to using administrative data, we estimate that 18.4% of the residents in this area did not benefit from a specialized consultation about their cancer care, which could also have included suitability and timing of referral to the palliative care clinic. Specific strategies directed towards older and rural patients may help to address this important access to care issue. Citation Format: Michael Conlon, Mark Hartman, Barbara Ballantyne, Mary Bewick, Margaret Meigs, Natalie Aubin, Andrew Knight. Access to medical or radiation oncology consultation in patients who died from cancer in the Sudbury-Manitoulin District of Northeastern Ontario, Canada. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4141. doi:10.1158/1538-7445.AM2014-4141

Patterns of Referral to Radiation Oncology Among Patients Who Undergo Cystectomy for Invasive Bladder Cancer in Ontario: A Population-Based Study

Radical radiation therapy (RT) is a reasonable alternative to cystectomy for some patients with invasive bladder cancer, and post-operative RT may be indicated in selected patients who are at high risk of local recurrence. The purpose of this study was to determine the frequency of pre- and post-operative radiation oncology (RO) consultation among patients who undergo cystectomy for bladder cancer in Ontario.