Radiation Oncology Consultation Research Articles

Abstract A047: An ethnographic study of African American men's prostate cancer treatment decision-making

Abstract Purpose: Compared to White men, African American men bear a disproportionate burden of prostate cancer (PCa), including higher mortality, widespread undertreatment, and greater dissatisfaction with care and decisional regret. We explored the process of treatment decision-making to inform future interventions to achieve patient-centered communication and guideline-concordant care. Methods: We conducted an ethnographic cohort study at two public hospitals following African American men newly diagnosed with PCa, from diagnosis through treatment decision. Data sources included audio-recorded observations of urology and radiation oncology appointments, field notes from observations of multiple clinic appointments, and two in-depth interviews with patients (post-diagnosis and post-treatment decision). We explored how patients chose their treatment, who they consulted, and the information they sought. Audio recordings of clinic appointments and in-depth interviews were transcribed verbatim. We used an iterative process of coding and team discussion to conduct a thematic analysis of qualitative data to examine the experiences, refine codes, and identify key themes. Results: Among 16 African American men diagnosed with PCa, four key themes emerged regarding treatment decision-making: feelings of anxiety/fear, impact of others' cancer narratives, interactions with clinical team, and sociocultural support. Men expressed a desire to quickly get past PCa due to anxiety/fear and viewed surgery as their best option to achieve this goal. Patients' sense of urgency varied based on diagnosis (low-risk vs. intermediate- or high-risk PCa). Many men reflected on negative things they heard from other people's cancer experience, often not related to PCa, which elevated their own apprehension of certain treatment options. Patients expressed confidence in and level of comfort with their urologist and his/her recommendation, despite the absence of a second opinion or radiation oncology consultation. Notable sociocultural dynamics emerged, such as men hiding their diagnosis from family, and family members questioning care plans (e.g., active surveillance vs. active treatment). Partners, family members, and friends played an important role, despite their absence at clinic appointments. Conclusions: Study results thus far reveal a range of influences on PCa treatment decision-making among African American men, including fear/anxiety and sociocultural networks that may contribute to rushed and ill-informed decisions. A more nuanced probing of sociocultural aspects is needed. Future studies should further explore these factors as nodes shaping decision trajectories, and therefore as potential points for intervention. For example, educational efforts might highlight the availability of time to consider treatment options and the value of second opinions. PCa survivors' stories could also be a powerful resource, although efforts may need to demystify misinformation that incites fear. Citation Format: Nynikka R. Palmer, Richard L. Street, Dean Schillinger, Janet K. Shim, Sarah D. Blaschko, Benjamin N. Breyer, Rena J. Pasick. An ethnographic study of African American men's prostate cancer treatment decision-making [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A047.

Quality Improvement Initiative to Enhance Multidisciplinary Management of Malignant Extradural Spinal Cord Compression.

To determine if a quality improvement (QI) initiative could enhance multidisciplinary management of acute malignant extradural spinal cord compression (ESCC) at our institution. The medical records of all 40 patients who received palliative radiotherapy for malignant ESCC from 2015 to 2017 were reviewed to determine the time course of key National Comprehensive Cancer Network guideline-supported workup and management steps. On the basis of the findings, a multidisciplinary group of physician stakeholders developed a clinical pathway to facilitate expedited care. The efficacy of this clinical pathway and the educational content provided to all relevant departments were then evaluated by comparing outcomes with data from a similarly reviewed follow-up cohort of 25 patients from 2018 to 2019. Patients treated for malignant ESCC after our QI intervention were more likely to undergo magnetic resonance imaging (MRI) of the entire spine (64% v 44%; P = .013) and have a radiation oncology (RO) consultation before surgery (100% v 27%; P = .002). Median time from MRI to RO consultation decreased from 3 to 1 days (P = .03). On subgroup analysis, initial trends toward delays in RO consultation for patients planning for surgery (median, 3 days) or for lack of prior cancer diagnosis (median, 4 days) were reduced to delays of 0 and 1 day, respectively, after the QI intervention. No significant differences were observed in time to surgical consultation or surgery itself. This QI study was able to stimulate better use of diagnostic imaging and earlier involvement of RO in multidisciplinary decision making, suggesting an effective approach to improving multidisciplinary care in other scenarios as well.

Thoracic Radiation Oncology Clinical Trial Accrual and Reasons for Nonenrollment: Results of a Large, Prospective, Multiyear Analysis

Clinical trials are considered the gold standard in evidence-based medicine, yet few patients with cancer ultimately enroll. Here we examine patients screened for thoracic radiation oncology clinical trials to better understand enrollment trends. A prospective database tracking screening and enrollment for patients referred for thoracic radiation oncology consultation at our institution from 2016 to 2019 was evaluated. Proportional enrollment rates, patient and disease characteristics, self-reported socioeconomic factors, and reasons for ineligibility or nonenrollment across 17 radiation therapy trials were compared. Enrollment data on 2372 patients were available for analysis. Of these patients, 40.0% (949) were deemed "not eligible" (NE) for any trial or were unwilling to be further screened. Reasons for ineligibility included stage (44%), histology (13%), radiation therapy not indicated (12%), patient decision (7%), and enrollment in a competing medical or surgical oncology trial (5%). The remaining 60.0% (1423) were "potentially eligible" (PE) for one or more trials. Most had non-small cell lung cancer (71%) or esophageal cancer (16%), and there were significantly fewer stage IV PE (29%) versus NE (49%) patients (P < .0001). Of 2372 patients, 281 (11.9%) enrolled. Notable reasons for nonenrollment were inclusion and exclusion criteria (58%), patients declining enrollment (14%), and physician decision (5%). The proportion of white patients was higher in the PE versus NE group (82.5% vs 75.8%; P < .001). Additionally, white race (87.9% vs 81.2%; P = .008), English language preference (96.4% vs 92.9%; P = .032), and non-Hispanic/Latino ethnicity (94.0% vs 90.1%; P = .042) were significantly different in enrolled versus nonenrolled PE patients. Only 12% of patients screened for radiation therapy trials ultimately enrolled, and more than two-thirds had no trial available or were found ineligible. In addition, 19% of potential eligible patients did not enroll because the patient or physician declined. Future trials may benefit from pragmatic designs with more inclusive enrollment criteria and multidisciplinary engagement of referring providers.

Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment.

Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes. In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N - 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model. Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy. At the authors' institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.

Timing of referral for palliative radiation therapy and length of hospital stay.

57 Background: Palliative radiation therapy (PRT) offers effective symptomatic relief to cancer patients. Increased focus on quality of care and healthcare efficiency necessitate a better understanding of the temporal relationships between consultation for/initiation of PRT and length of hospital stay (LOS). This study aims to assess whether durations from admission to PRT consult/PRT initiation affect LOS. Methods: In an institutional review of patients who received PRT as inpatients between January 2017 and December 2018, 67 met inclusion criteria. Duration of time from admission to consultation or start of PRT were categorized using various thresholds. LOS was compared across groups using the Wilcoxon rank sum test and factors were evaluated as predictors of LOS using bivariate linear regression. Results: PRT was given for pain (37%), neurologic deficits/brain metastases (31%), and respiratory symptoms (19%). Multiple sites were treated in 31%; treatment sites included spine (45%), non-spine bone (27%), chest (22%), abdomen/pelvis (12%), brain (10%) and soft tissue (6%). At admission, patients had known metastases (66%), no prior cancer diagnosis (19%), or known primary cancer (15%). Median LOS was 12 days (IQR 7-18) for all patients. There was a significant difference in LOS for patients referred for PRT within 3 days of admission versus greater than 3 days (11 v. 21 days, p &lt; 0.01). This difference was slightly greater using a threshold of 4 days (11 v. 25 days, p &lt; 0.01) and 5 days (11 v. 26 days, p &lt; 0.01), both of which remained significant when analyzing only patients with prior cancer diagnosis (n = 54). There was no difference in LOS using a threshold of 1 or 2 days. As a continuous variable, duration from admission to PRT was associated with LOS (OR 2.40, p &lt; 0.01). Similar patterns were noted when analyzing by time from admission to PRT start. Conclusions: Earlier radiation oncology consultation for PRT is associated with shorter LOS in patients treated with PRT for symptomatic malignancy. Further research is needed to better define this relationship and improve systematic processes to facilitate early consultation and treatment. A palliative radiation oncology clinic was recently developed to address these issues at our institution.

Stereotactic Radiosurgery and Intensity Modulated Radiotherapy for Treatment of Paragangliomas: A Tertiary Medical Center’s 17 Year Experience

Stereotactic radiosurgery (SRS) and intensity modulated radiotherapy (IMRT) are alternative therapies to surgery in the treatment of paragangliomas (PG). We hypothesized that SRS and IMRT could achieve adequate local control (LC) and symptom (sx) control in the treatment of PG with minimal associated toxicity in both upfront and salvage settings. We retrospectively evaluated 31 tumors in 30 non-metastatic patients (pts) treated with linear accelerator (LINAC) based SRS or IMRT at our institution between 2000-2017 for local tumor control and risk of secondary malignancy in an IRB approved study. SRS vs. IMRT was chosen based on PG size and location. Sx control and toxicities were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. PG were measured on MRI at radiation oncology (RO) consultation and at last follow up (f/u). Long axis (LA), short axis (SA), and largest craniocaudal dimensions (CC) were compared. LC was defined as no increase in LA, SA, or CC ≥ 3 mm and no salvage therapy by last f/u. Median f/u was 4.16 years. 6 pts were treated for residual disease status post (s/p) surgery, 6 pts had recurrent disease s/p surgery, and 18 pts (19 PG) received radiotherapy (RT) as primary treatment. Smallest PG dimension ranged 0.72-3.41cm and largest dimension 1.42-5.21 cm. 25 pts received SRS (median largest dimension 2.5cm): 13 in 5 fractions (range 2250-3000 cGy), 3 in 3 fractions (2100-2800 cGy) and 9 in 1 fraction (1400-1800 cGy). 4 pts (one with two PG) received IMRT in 15-27 fractions (range 4500-5400 cGy, average largest dimension 4.17 cm). All pts had tumor-induced neurologic sx’s at RO consultation. 23 pts (76.7%) had improvement in at least one PG-induced sx by last f/u. At last f/u imaging, 30 tumors (93.8%) decreased in at least one dimension, median largest decrease 3.6 mm (range 0-17.6 mm). No tumors increased ≥ 3mm and no pts required salvage therapy (100% LC), developed metastatic disease, or developed secondary malignancy with combined 132.43 years of f/u. No SRS pts experienced acute Gr ≥3 toxicity. IMRT toxicity included Gr 3 hearing loss in one patient with baseline hearing decline, and 1 pt with Gr 3 mucositis and skin rash. SRS and IMRT are safe and effective alternatives to surgical resection of paragangliomas with high LC rates, minimal acute and late complications, notable improvement of baseline symptoms, and without occurrence of any secondary malignancy or treatment failures requiring re-intervention. Radiotherapy was equally effective as primary treatment, after subtotal resection, or after progression s/p surgery.

Relationship Between Intern Experience and Inpatient Consults to Radiation Oncology

Each July, the nation’s newest physicians arrive on the wards to begin their practice of medicine. During a patient’s hospital course, it is common to consult specialty services to assist in management. Radiation Oncology (RO) is a specialty which receives little attention in most medical school curriculums. Unlike other specialties, inpatient consultations are usually reserved for urgent cases where routine management is deferred to the outpatient setting. Understanding which patients can benefit from inpatient RO evaluation is a nuanced skill that is difficult to acquire quickly. Minimal research has been conducted in this area. Therefore, we sought to compare after-hours consults placed by “experienced” versus “novice” interns, with the hypothesis that novice interns would request inpatient consults more frequently. At our institution, “after-hours” is from 5 PM - 8 AM on weeknights, the entire weekend, and on national holidays. During this time, calls to the department are forwarded to an answering service who pages an on-call resident. The answering service keeps logs of all calls received. Call records from May - August 2018 were analyzed. For each call, the following information was obtained: date and time, patient date of birth, was the call from a provider or a patient, and, if the call was from a provider, was it an inpatient consult or some other issue (e.g. critical test result). Using the time of the academic year as a surrogate, calls were separated into “experienced” (May and June) or “novice” (July and August) groups, with July 1st, 2018 as the division point. Descriptive statistics and a two-proportion two-sided Z-test were performed using Statistical analysis software. Statistical significance was set at p-value <0.05. A total of 161 after-hours phone calls were received in the four-month study period. The majority of calls were received on a Sunday (24.8% of total calls). The average time to receive a call was 2:15 PM (range: 02:30 AM - 12 AM). The average patient age was 65 (range: 15 to 95). From May 1st to June 30th a total of 89 phone calls were received. 72 calls were received from July 1st to August 31st. Significantly fewer after-hours inpatient consults were placed in July and August (5 calls, 6.9%) compared to May and June (16 calls, 17.9%) (z = 4.272, p = 0.039). Contrary to our hypothesis, significantly fewer after-hours inpatient consults were received during the period staffed by novice interns compared to experienced interns. This could be attributed to the fact that consultation to RO was not considered in the after-hours period where house staff have less oversight. Instead, inpatient consults might be more likely to be placed during the day at the suggestion of senior residents, fellows, or attendings, and these consults would not be captured by this database. More research into the understanding of inpatient RO consultation is warranted.

Breast Cancer Patients' Perceptions of Adjuvant Radiotherapy: an Assessment of Pre-Treatment Knowledge and Informational Needs.

There is little knowledge about breast cancer patients' information-seeking behaviors, needs, and perceptions of breast radiation therapy (BRT) prior to radiation oncology consultation. This study assessed these parameters to evaluate potential gaps and overlaps in the BRT educational process. Breast cancer patients > 18years referred for adjuvant BRT at a tertiary cancer center completed an anonymous survey prior to their consultation. Response rate was 86% (118/137). The most commonly reported sources of information about BRT were healthcare providers (55%), family or friends treated with BRT (53%), and the Internet (45%). Most (79%) had little or no knowledge about BRT. Sixty-seven percent were a little or moderately concerned about BRT, while 29% were very concerned. Half were unsure about the benefit of BRT and 46% thought it would provide a moderate to significant benefit. While seeking information about BRT, a wide range of topics were encountered. The most common ones were fatigue (68%), skin care (57%), skin problems (54%), effects on healthy body tissues (43%), the immune system (37%), and pain (34%). Topics considered most important for the radiation oncologist to address were BRT effects on the heart (74%), second cancers (74%), immune system (66%), pain (64%), and lungs (62%). Although commonly encountered, fatigue (56%) and skin care (49%) were of lesser importance. In conclusion, breast cancer patients encounter a broad range of information about BRT prior to their radiation oncology consultation, which may contribute to worry and misconceptions. Potentially rare and serious side effects were considered important to address.

Implementation of a rapid access multidisciplinary bone metastases clinic to improve access to care at a large cancer center.

79 Background: MD Anderson Cancer Center is a large cancer center with 44,000 new patients per year. Radiation therapy (RT) is an effective treatment for bone metastases that can reduce pain medication use and improve quality of life. Our goal was to assess the effect of implementing a rapid access multidisciplinary clinic for bone metastases (RABC). Methods: RABC was instituted to schedule patients for radiation oncology and orthopedic surgery consult within 48 hours of referral. Same day simulation and treatment times were held for these patients for one 8Gy fraction. Thirty sequential patients treated with one fraction to bony sites in the outpatient setting prior to implementation of the clinic were chosen as a comparison group. Time from consult order to consult visit (OTV) and from consult visit to treatment completion (CTT) were recorded, in addition to frequency of multidisciplinary care (MDC; orthopedic surgery and radiation oncology). Overall Time (OT) was calculated from referral to treatment completion. T-test and chi-square test were used for analyses. Results: Between April 2018 and July 2018, 72 patients were referred to RABC. 23 patients were seen in consultation and received RT. Sites treated were pelvis (N = 10), spine (N = 6), lower extremity (N = 4) and upper extremity (N = 3). Patients had one site (N = 20), two sites (N = 2) or three sites treated (N = 1). Histologies included breast (N = 5), thoracic (N = 7), gastrointestinal (N = 6), genitourinary (N = 2) and head/neck (N = 2). OTV was shorter for RABC patients (mean 3.3 [+/-5.7] vs. 9.5 days [12.4]; p = 0.02). CTT was also significantly shorter for RABC patients (mean 5.4 hours [+/-1.8] vs. 6.5 days [+/-6.5]; p &lt; .0001). OT was also shorter (3.5 days [+/-5.6] vs. 16.4 days [+/-14.8]; p &lt; .0001). RABC clinic patients were more likely to receive MDC (100% vs 28%; p &lt; .0001). Conclusions: The rapid access bone metastases clinic significantly decreased overall time from consult to completion of treatment and also decreased time to access radiotherapy. Patients were also more likely to receive multidisciplinary evaluation. The RABC approach is a promising model to improve palliation for patients with painful bony metastases.

Telehealth in radiation oncology at the Townsville Cancer Centre: Service evaluation and patient satisfaction

PurposeTelehealth (TH) in Radiation Oncology at Townsville Cancer Centre (TCC) was implemented in July 2011 to provide cancer care closer to home to the regional and rural population. The aim of this study was to describe the service use and patient satisfaction. Materials and methodsA retrospective audit of records was conducted for patients treated at TCC between July 2011 and December 2015. Data included patient demographics, diagnosis and treatment. Results of a patient satisfaction survey were summarised through descriptive statistics. ResultsA total of 1530 TH consultations were provided to 833 patients. 311 patient charts were audited (615 TH, 650 in-person, 151 phone consultations). Median distance from TCC to satellites was 327.3 km (21.6 to 1130.1). 71% were male and median age was 65 (23–94 years). Cancer diagnoses included prostate (32%), breast (12%) and head and neck (10%). 60% of patients underwent radiation therapy for curative intent, 22% palliative and 18% did not undergo treatment. 106 patients participated in the satisfaction survey (231 patients invited, response rate of 46%), with the overall positive response mainly attributed to advantages in travel and time savings. 54.7% of patients selected TH as their preference for future consultations, 34.9% indicated a mix of TH and in-person consultations, and only 1 patient (0.9%) indicating in-person only. ConclusionTH enables the delivery of radiation oncology consultations to rural and regional patients, with an overall high level of patient satisfaction. Patients welcomed the model for benefits of travel and time savings. Future directions include engaging with specialist, rural medical staff and patients to maximize access.

Delays in Care for Non-English Speaking Patients with Breast Cancer Undergoing Radiation Therapy

Language discrepancies create barriers to healthcare that may impact a patient’s course of care including delays in diagnosis, biopsy, resection, and radiation treatment. The aim of this study was to determine if non-English speakers (NES) experience treatment delays within their path to radiation treatment compared to English-speaking patients. NES patients diagnosed with breast cancer and treated with radiation between 2016 and 2017 (n=67) were matched with English-speaking patients based on sex, age, cancer stage, and chemotherapy (neoadjuvant or adjuvant). A total of 27 NES were matched to 40 English speakers; 13 NES were matched to 2 English-speakers and 14 NES were matched to one English speaker. Conditional logistic regression on matched data was used to compare time between diagnostic mammogram and biopsy, resection, Radiation Oncology consult, and start of radiation treatment. We also evaluated the time from resection to Radiation Oncology consult, resection to start of radiation treatment, and Radiation Oncology consult to start of radiation treatment. The time from diagnostic mammogram to diagnostic biopsy was significantly longer for NES compared to English-speaking patients (p= 0.0322), with an average difference of 25 days and an odds ratio of 1.043, 95%CI [1.003, 1.102]. A one-week increase in time to biopsy increased the odds of a patient being NES by 34% (p=0.0322). Although not statistically significant, similar time delay trends were observed between NES and English-speaking patients for time from diagnostic mammogram to resection (p=0.0703), diagnostic mammogram to Radiation Oncology Consult (p=0.0702), and diagnostic mammogram to start of radiation treatment (p=0.0848). We did not observe a difference in time from resection to new visit (p=0.2197) or resection to start of treatment (p=.2004). Independent of sex, age, race/ethnicity, and receipt of chemotherapy, language predicted delays in care for patients undergoing treatment for breast cancer. The most pronounced delay in care for NES was the time from diagnostic mammogram to diagnostic biopsy. However, notable trends were observed as NES patients progressed to resection, Radiation Oncology consult, and the start of radiation treatment. Additional analyses are underway for a larger matched cohort to build on these findings. These results provide preliminary data to help guide future interventions for improving healthcare delivery for Non-English speaking patients.

Use of radiotherapy for bladder cancer: A population-based study of evolving referral and practice patterns.

Definitive treatment for muscle-invasive bladder cancer includes either cystectomy or radiotherapy (RT). We describe use of RT and radiation oncology (RO) referral patterns in the contemporary era. The Ontario Cancer Registry and linked records of treatment were used to identify all patients who received cystectomy or RT for bladder cancer from 1994-2013. Physician billing records were linked to identify RO consultation before radical treatment. Multilevel logistic regression models were used to examine patient factors and physician-level variation in referral to RO and use of RT. A total of 7461 patients underwent cystectomy or RT for bladder cancer from 1994-2013; 5574 (75%) had cystectomy and 1887 (25%) had RT. Use of RT decreased from 43% (126/289) in 1994 to 23% (112/478) in 2008 and remained stable from 2009-2013 (23%, 507/2202). RO referral rate among all cases decreased from 46% (134/289) in 1994 to 30% (143/478) in 2008; however, the rates began to rise in the contemporary era from 31% (137/442) in 2009 to 37% (165/448) in 2013 (p=0.03). Patient factors associated with use of RT include older age, greater comorbidity, and geographic location. Surgeon-level factors associated with greater preoperative referral to RO include higher surgeon case volume and practicing in a teaching hospital. One-quarter of patients treated with curative intent therapy for bladder cancer receive RT. While referral rates to RO are increasing, future data will identify the extent to which this has altered practice. Collaborative efforts promoting multidisciplinary care and RO consultation before radical treatment are warranted.

Utilization of Radiotherapy for Bladder Cancer: Evolving referral and practice patterns in the general population

IntroductionDefinitive treatment for muscle invasive bladder cancer (MIBC) includes either cystectomy or radical radiotherapy (RT). Despite the growing evidence suggesting that cystectomy and RT may offer comparable survival benefit, utilization of RT and referral rate to radiation oncology (RO) have historically been low in routine practice.&#x0D; Objectives and ApproachThe aims were to describe the use of RT and RO referral patterns in the contemporary era. A retrospective cohort study was conducted by linking administrative treatment records with the Ontario Cancer Registry to identify all patients who received treatment with curative intent for bladder cancer in Ontario from 1994-2013. Physician billing records were linked to identify RO consultation before radical treatment. Practice patterns in the contemporary era (2009-2013) were compared with data from 1994 to 2008. Multilevel (patient-, surgeon- and hospital-level) logistic regression models were used to examine sociodemographic and organizational variation in referral to RO.&#x0D; ResultsIn total, 7461 patients underwent cystectomy or RT for bladder cancer in Ontario from 1994-2013; 5574 (75%) had primary cystectomy and 1887 (25%) primary had RT. Use of RT decreased from 43% in 1994 to 23% in 2008 and remained stable during 2009-2013 (23%). RO referral rate among all cases decreased from 46% in 1994 to 30% in 2008; however, the rates began to rise in the contemporary era from 31% in 2009 to 37% in 2013. A similar trend was seen in preoperative referral rate among patients treated with cystectomy (11% in 1994-1998, 9% in 1999-2008, and 14% in 2009-2013). Patient, surgeon, and hospital-level factors associated with preoperative referral to RO include older age, year of cystectomy, higher surgeon case volume, and teaching hospital.&#x0D; Conclusion/ImplicationsA minority of patients underwent curative intent therapy for bladder cancer received RT. Recent data suggest that referral rates to RO are increasing; future data will identify the extent to which this has altered practice. Collaborative efforts promoting multidisciplinary care and RO consultation at the urologist and hospital-level are warranted.

The effect of selection and referral biases for the treatment of localised prostate cancer with surgery or radiation

BackgroundConsultation with radiation oncologists, in addition to urologists, is advocated for patients diagnosed with prostate cancer. Treatment patterns for patients receiving consultation from radiation oncologists in addition to urologists have not previously been described.MethodsWe conducted a matched cohort study of men with newly diagnosed non-metastatic prostate cancer in Ontario, Canada. Patients who underwent consultation with a radiation oncologist prior to treatment were matched 1:1 with patients managed by a urologist alone based on tumour and patient characteristics. We examined rates of active treatment (surgery or radiotherapy) within one year following diagnosis.ResultsAmong 5708 matched pairs (11,416 patients), those who received radiation oncology consultation were more likely to undergo active treatments whether they had intermediate or high-risk disease (88.6% vs. 65.9%, p < 0.0001; adjusted odds ratio 4.0, 95% CI: 3.6–4.4) or low-risk disease (56.1% vs. 13.3%, p < 0.0001; adjusted odds ratio 8.4, 95% CI: 6.7–10.6). This effect persisted after considering age, comorbidity, tumour volume and year of diagnosis.ConclusionsPatients newly diagnosed with prostate cancer who receive radiation oncology consultation are associated with a higher rate of active treatment, compared to patients managed by urologists only. Selection and referral biases, and unmeasured confounding such as patient preference must be considered as important factors attributing this association.

Prostate Clinical Outlook Visualization System for Patients and Clinicians Considering Cyberknife Treatment—A Personalized Approach

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 the potential radiobiological advantages. The Prostate Clinical Outlook Visualization System (PCOVS) 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 outcomes—for each prospective patient using the EPIC-26 quality of life parameters based on clinical outcomes data of 580 prostate cancer patients who were treated with SBRT. We applied Kaplan-Meier analysis using the ASTRO definition for biochemical recurrence (BCR) free survival and likely outcome and the PCOVS nomogram to calculate parameters for quality of life. Open-source R, RShiny, and MySQL were used to develop a modularized architecture system. Results: The PCOVS presents patient specific risk scores in a gauge chart style and risk free probability bar plots to compare the treatment data of patients treated with SBRT. The PCOVS generates reports, in PDF, which consists of a comparison charts of risk free probabilities late effects and gauge charts of risk scores. This system is now being expanded as a web-based service to patients. Conclusions: The PCOVS 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 PCOVS approach can be expanded to other specialties of oncology with the flexible, modularized architecture, which can be customized by changing independent modules.

A Palliative Radiation Oncology Consult Service Reduces Total Costs During Hospitalization

ContextPalliative radiation therapy (PRT) is a highly effective treatment in alleviating symptoms from bone metastases; however, currently used standard fractionation schedules can lead to costly care, especially when patients are treated in an inpatient setting. The Palliative Radiation Oncology Consult (PROC) service was developed in 2013 to improve appropriateness, timeliness, and care value from PRT. ObjectivesOur primary objective was to compare total costs among two cohorts of inpatients with bone metastases treated with PRT before, or after, PROC establishment. Secondarily, we evaluated drivers of cost savings including hospital length of stay, utilization of specialty-care palliative services, and PRT schedules. MethodsPatients were included in our observational cohort study if they received PRT for bone metastases at a single tertiary care hospital from 2010 to 2016. We compared total costs and length of stay using propensity score-adjusted analyses. Palliative care utilization and PRT schedules were compared by χ2 and Mann-Whitney U tests. ResultsWe identified 181 inpatients, 76 treated before and 105 treated after PROC. Median total hospitalization cost was $76,792 (range $6380–$346,296) for patients treated before PROC and $50,582 (range $7585–$620,943) for patients treated after PROC. This amounted to an average savings of $20,719 in total hospitalization costs (95% CI [$3687, $37,750]). In addition, PROC was associated with shorter PRT schedules, increased palliative care utilization, and an 8.5 days reduction in hospital stay (95% CI [3.2,14]). ConclusionThe PROC service, a radiation oncology model integrating palliative care practice, was associated with cost-savings, shorter treatment courses and hospitalizations, and increased palliative care.

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% &gt; 65, 41% from 50-65 and 20% &lt; 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 ( &gt; 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.