Use Of Palliative Radiotherapy Research Articles

A 15-Year Single-Institution Retrospective Study of Primary Pancreatic Cancer Treated with Non-Ablative Palliative Radiotherapy.

We studied the use of palliative radiotherapy (RT) among patients with primary, non-curable, locally advanced pancreatic cancer. In this subset of patients, with very poor survival, various palliative RT dose fractionation schemes are used; but, in the absence of a guideline, practice patterns vary, and dose choice is mainly based on the physician's intuition. We divided the patients into three groups, according to the dose fractionation schedules received: low (A), intermediate (B), and high (C) dose groups, to study the potential differences in outcome between the different dose prescriptions. Cohort: n = 184. Median age: 69 years. Male: n = 105 (57%), female: n = 79 (43%). Stage IV: n = 117 (64%). T4: n = 127 (69%). Tumor location: head: n = 109 (59%), body: n = 37 (20%), tail: n = 25 (14%), neck: n = 11 (6%), and uncinate: n = 2 (1%). Prior systemic therapy: n = 66 (36%). Most common dose fractionations received: 20 Gy in five fractions n = 67 (36%), 30 Gy in 10 fractions n = 49 (27%), and 8 Gy in one fraction n = 23 (13%). Group A: n = 33 (18%), median overall survival (OS) 19 days (95% CI 4-33). Group B: n = 84 (46%), median OS 52 days (95% CI 43-60). Group C: n = 67 (36%), median OS 126 days (95% CI 77-174). Median days to in-field progression: Group A 59 days (range 7-109), Group B 96 days (range 19-173), and Group C 97 days (range 13-475). To our knowledge, this is the largest reported retrospective cohort of patients receiving non-ablative palliative RT to treat their primary pancreatic tumors. Most patients had metastatic disease, T4 tumors of the pancreatic head and had not received prior systemic therapy. A significant survival benefit was seen favoring the high dose/longer RT fractionation group, presumably due to appropriate patient selection rather than an RT effect. Despite the relatively short median overall survival, one fifth of the patients were found to experience an in-field progression following RT.

Survival Following Palliative Radiotherapy for Head and Neck Squamous Cell Carcinoma: Examining Treatment Indications in Elderly Patients.

This study investigated the survival outcomes of patients with head and neck squamous cell carcinoma (HNSCC) undergoing palliative radiotherapy, particularly focusing on challenges and factors associated with older age, providing insights into appropriate palliative radiotherapy use in this demographic. A retrospective study was conducted using electronic medical records of 73 patients with HNSCC who were deemed unsuitable for curative therapy. Palliative radiotherapy involved a uniform dose of 30 Gy in 10 fractions. Survival analysis was performed using Kaplan-Meier method, and multivariate analysis identified significant prognostic factors. The median overall survival was 7.5 months, with no significant difference between age groups. Karnofsky performance status (KPS) >70 correlated with favorable survival. Multivariate analysis confirmed KPS as an independent prognostic factor (hazard ratio=1.949, p=0.031). The results of this study align with those of previous studies, emphasizing the importance of palliative radiotherapy for HNSCC treatment. Optimal dose fractionation regimens remain undetermined, and tailored approaches that consider factors, such as age and performance status are crucial. Individualized, comprehensive assessments and supportive care measures enhance patient well-being, reflecting palliative care principles.

Palliative Radiotherapy for Haemostasis in Malignancy: a Systematic Review

AimsPalliative radiotherapy is commonly used to achieve haemostasis for malignancy-induced haemorrhages. Our study aimed to examine the efficacy of palliative radiotherapy in the control of haemorrhages caused by various types of malignancy. Materials and methodsA systematic review of the literature was conducted to determine the level of evidence for the use of palliative radiotherapy in achieving haemostasis. Searches of the Medline, Embase and Cochrane databases were completed for studies published between January 1947 and May 2017. Studies that reported either a qualitative or a quantitative effect of radiotherapy were selected for inclusion during the review process. ResultsIn total, 836 abstracts were screened; 13 prospective and 45 retrospective studies met the criteria for inclusion in the review. Selected studies were sorted based on the underlying tumour type to provide readers the opportunity to compare dose and fractionation schedules. Significant variations in reporting of outcomes and low total patient numbers did not allow for a quantitative analysis to be carried out. A higher median dose and a hypofractionated schedule seem to provide numerically higher rates of control based on the available data. ConclusionsPalliative radiotherapy is useful in the management of bleeding related to advanced and incurable malignancies. Brachytherapy seems to be effective in haemostasis of certain malignancies, especially that of gynaecological origin. Treatment should be tailored to individual patient situations given the palliative goals of any such therapy. Further prospective studies could help to delineate optimal dose and fractionation schedules.

PD-0073 Overcoming the barriers to the use of palliative radiotherapy in patients with bone metastasis

PD-0073 Overcoming the barriers to the use of palliative radiotherapy in patients with bone metastasis

Palliative extracranial radiotherapy in patients receiving immunotherapy for non-small cell lung cancer: a narrative review.

Role of radiotherapy (RT) in the era of immuno-oncology (IO) in advanced non-small cell lung cancer (NSCLC) is rapidly changing. RT is not only intended for addressing palliation symptoms but also is considered as a potential tool potentializing an immunogenic effect of given drugs. However, the best timing, techniques, doses, volumes, and its use for asymptomatic patients is a subject of research. We performed a review on the role of palliative RT schedules in combination with IO for advanced NSCLC. Indications in symptomatic and asymptomatic patients, outcomes, toxicity, and possible developments are discussed. A literature search was conducted in MEDLINE and PubMed databases and clinicaltrials.gov using the keywords 'lung cancer' AND "immunotherapy" AND 'radiotherapy' OR "palliative radiotherapy". Body of evidence indicate that palliative RT used in combination with IO is effective in terms of symptom management and safe; does not increase the risk of serious side effects, including serious pulmonary toxicity. We have limited data evidencing improvement of survival by addition of short ablative RT dose to one site of the disease to IO in oligometastatic NSCLC. Some data indicate that short ablative doses of stereotactic body radiation therapy (SBRT) are more effective with regard to treatment response and survival than protracted RT schedule with lower fractional doses. However, this may be a selection bias of better prognostic patients who underwent SBRT. The use of steroids being a potential concern during IO should not be prohibited if clinically indicated during palliative RT. Its detrimental effect shown in some studies may also be a result of selection bias, because steroids given for not cancer-related causes during IO did not decrease survival. RT for symptom management may be used during, directly before or after IO. This has a potential to ease symptom burdens and improve performance status (PS). However, still more studies are needed to establish optimal guidelines in asymptomatic patients for appropriate timing, volumes, dose, and fractionation schedules of palliative RT use in combination with IO.

Radiotherapy activity in the COVID 19 pandemic: Brazil's operational national-level study

PurposeDuring the COVID-19 pandemic, patients with cancer are at increased risk of not having timely diagnosis and access to cancer treatment. The present study evaluated the COVID-19 pandemic impact on radiotherapy activity in Brazil. MethodsA national-level study was performed to evaluate the RT utilization for prostate, breast, head & neck (HN), Gynecology (GYN), Gastrointestinal (GI), lung cancers, and bone/brain metastases. The data on the RT executed was extracted from the Brazilian Ministry of Health database. The NON-COVID period was considered the control group, and the comparison groups were COVID-2020 (without vaccine) and COVID-2021 (with vaccine). ResultsWe collected the data of 238,355 procedures executed on three periods. Significant difference in the RT utilization between NON-COVID and COVID-2020 were observed for prostate cancer, bone and brain metastases (−12.3 %, p = 0.02, +24 %, p = 0.02 and +14 %, p = 0.04, respectively). Comparing 2 equivalents months from NON-COVID-2019 (ref), COVID-2020, and COVID-2021, a significant increase was identified for bone and brain metastases (2020 +21 %, and 2021 +32 %), and (2020 +20 %, and 2021 +14 %). A stable drop occurred for prostate cancer (2020 −11 % and 2021 −10 %), and a variation was observed for breast (2020 +8 %, and 2021 −1 %) and lung cancer (2020 +10 %, and 2021 −3 %). For other cancers, non-significant changes were observed when comparing 2020 and 2021. ConclusionThe RT activity was heterogeneously affected with a substantial increase for bone and brain metastases and a meaningful decline for prostate cancer. Policy summaryWith a significant increase in the use of palliative radiotherapy for bone and brain metastases and a meaningful reduction in curative radiotherapy for prostate cancer, we hope these findings can help governments, RT services, medical communities, and other stakeholders develop strategies to mitigate the impact of the present and future pandemics. Finally, despite the changes imposed by the COVID pandemic, it is imperative to enhance screening, increase cancer diagnosis at an early stage, and improve access to all cancer treatments, including radiotherapy.

The Use of Palliative Radiotherapy in the Treatment of Lung Cancer

There have been significant advances in the systemic treatment of stage IV lung cancer, which is now recommended first line in patients with adequate fitness. This includes some patients with brain metastases due to the increased understanding of the central nervous system penetration of targeted therapies. The trials evidence base for palliative radiotherapy pre-dated this routine use of systemic therapy in our practice, which means that the sequence and role of palliative radiotherapy are not currently well defined in the first-line treatment setting. However, due to its efficacy in symptom control, radiotherapy remains a core component in the palliative management of lung cancer, particularly in the second-line setting and those unsuited to primary systemic treatment. This overview focuses on the evidence behind palliative radiotherapy to the thorax and brain for non-small cell and small cell lung cancer and the potential for future studies, including the TOURIST Trial Platform, to guide the future direction of these treatments.

Racial Disparities in the Use of Palliative Radiotherapy for Black Patients With Multiple Myeloma in the United States

<h3>Purpose/Objective(s)</h3> Multiple myeloma (MM) is a hematologic malignancy that disproportionately affects African Americans (AA) and has a natural history that is often characterized by painful osseous lesions that are amenable to palliative radiotherapy (RT). There are known racial disparities in the definitive treatment of MM and pain management in general in the AA community compared to other racial groups. We sought to determine if racial disparities also exist in use of palliative RT for MM in the United States. <h3>Materials/Methods</h3> The National Cancer Database was queried for patients 18 years and older who were diagnosed with MM from 2004-2016 and received radiation. RT dose was limited to between (and including) 4Gy to 30Gy to exclude non-standard doses, incomplete courses, and patients treated for plasmacytoma. The main independent variable under investigation was race/ethnicity, defined as non-Hispanic white (NHW), non-Hispanic black (AA), Hispanic, and other race. Outcomes of interest included receipt of palliative RT within 12 months of MM diagnosis and death within 30 days of initiation of palliative RT. Additional covariates included socioeconomic factors, underlying health, and treatment factors. Multivariable logistic regression analyses were performed to measure the associations of patient race/ethnicity with the odds receiving radiation within 12 months of diagnosis and odds of death within 30 days of receiving the first course of RT. <h3>Results</h3> Of 23,728 NCDB multiple myeloma patients receiving palliative RT within 12 months of diagnosis, 15.5% of NHW patients, 14.3% of AA patients, 15.8% of Hispanic patients, and 14.4% of other racial/ethnic group patients received palliative RT. The odds of receiving RT were 13% less for AAs compared to NHWs (OR = 0.87, CI = 0.83-0.90, <i>P</i> < 0.0001). Of those receiving radiation, the odds of dying within 30 days of RT were 18% less for AAs compared to NHWs (OR = 0.82, 95% CI = 0.67-1.00, <i>P</i> = 0.046). <h3>Conclusion</h3> This study of the NCDB demonstrates that in addition to previously documented disparities in definitive management of MM, AA patients are also less likely to receive palliative RT within 12 months of diagnosis and at the end of life.

Use of palliative radiotherapy among patients with metastatic non-small-cell lung cancer in Puerto Rico

BackgroundPalliative radiotherapy (RT) represents an important treatment opportunity for improving the quality of life in metastatic non-small cell lung cancer (NSCLC) patients through the management of symptoms within the course of the illness. The aim of the study is to determine the proportion of patients who had palliative RT within 12 months of diagnosis and evaluate the factors associated with it.MethodsA retrospective cohort study was performed using secondary data analysis from 2009 to 2015 from the Puerto Rico Central Cancer Registry–Health Insurance Linkage Database (PRCCR-HILD). A logistic regression model was used to examine factors associated with palliative RT.ResultsAmong the 929 patients identified with metastatic NSCLC, 33.80% received palliative RT within the first year after diagnosis. After adjusting for other covariates, receipt of chemotherapy (ORAdj = 3.90; 95% CI = 2.91–5.45; P < 0.001) and presence of symptoms (ORAdj = 1.41; 95% CI =1.00–1.98; P = 0.045) were associated with increased odds of palliative RT use. Although marginally significant, patients with private health insurance had increased odds of palliative RT use (ORAdj = 1.50; 95% CI = 0.98–2.29; P = 0.061) when compared to beneficiaries of Medicaid, after adjusting by other covariates.ConclusionsThe results of this study reveal concerning underuse of palliative RT among patients with metastatic NSCLC in Puerto Rico. Additional research is necessary to further understand the barriers to using palliative RT on the island.

Racial disparities in the use of palliative radiotherapy for black patients with multiple myeloma in the United States

Multiple myeloma (MM) is characterized by painful lesions that are amenable to palliative radiotherapy (PRT) but racial disparities may exist. In the current study, the National Cancer Database was queried for patients diagnosed with MM from 2004 to 2016 who received PRT. The percentages of patients receiving PRT within 12 months of diagnosis by race/ethnicity were: 15.5% non-Hispanic white (NHW), 14.3% African American (AA), 15.8% Hispanic, and 14.4% other. On multivariable logistic regression, the odds of receiving RT were 13% less for AAs compared to NHWs (OR = 0.87, 95% CI = 0.83–0.90, p < .0001) and the odds of dying within 30 days of PRT were 18% less for AAs compared to NHWs (OR = 0.82, 95% CI = 0.67–1.00, p = .046). This study highlights a health disparity affecting AA patients who despite having a higher incidence and mortality from MM are also less likely to receive PRT within 1 year of diagnosis and near the end of life.

The role of palliative radiotherapy in the management of elderly and frail patients with advanced bladder cancer: A survey by the AIROuro-group.

Radiotherapy (RT) is rarely used in the palliative management of muscle-invasive bladder cancer (MIBC). This survey aims to explore current care patterns within the Italian Radiation Oncologist community on this topic. In 2020, the uro-oncological study group of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) conducted a survey evaluating the RT role in advanced MIBC. An electronic questionnaire was administered online to the society members asking for: general considerations, patients' selection, and aim of the treatment, RT schedule and practical consideration, past and future perspective. Sixty-one questionnaires were returned (33% response rate). Most responders (62.30%) declared to work in a Center with a multidisciplinary uro-oncological team, and 8.20% to evaluate more than 20 patients with MIBC/year for palliative RT. Elderly patients were the most frequently evaluated (46.7%) and life expectancy was the most common selection criteria (44.60%). Thirty Gy in 10 fractions (58.9%), whole bladder as GTV (62.5%), PTV isotropic margins of 1.5-2cm (44.6%) and IMRT/VMAT technique (58.14%) were the most common treatment choices. Patients amenable for bladder palliative RT were most commonly referred by the urologist (43.86%) or the multidisciplinary team (38%). The reported main reasons for the low involvement of radiation oncologist in the management of MIBC patients were low attention to the palliative setting in bladder cancer (37.5%); radiation oncologist not involved in the management of these patients (32.1%); cases not discussed in the multidisciplinary board (26.8%). This survey illustrated the current use of palliative RT for patients with advanced MIBC in Italy and suggested the need for a greater involvement of radiation oncologists in their management.

Trends In Use Of Palliative Radiotherapy For Multiple Myeloma In The United States

Trends In Use Of Palliative Radiotherapy For Multiple Myeloma In The United States

Palliative Care Physicians and Palliative Radiotherapy, Knowledge and Barriers for Referring: A Cross-sectional Study

ContextPalliative radiotherapy is effective in the management of symptoms resulting from advanced cancer. However, it remains underutilized. In developed countries, many factors have been linked to this phenomenon but data in developing and low-income countries, particularly in Latin America, are lacking. ObjectivesTo conduct a cross-sectional survey to explore palliative care physicians' knowledge of palliative radiotherapy and to investigate possible factors that limit patient referral. MethodsThis is a cross-sectional survey. An online questionnaire was sent to palliative care physicians (n = 170) registered in the Chilean Medical Society of Palliative Care directory. ResultsThe overall response rate was 58.8%. Nearly all respondents (98%) considered radiotherapy to be a useful treatment. Less than half the respondents (43%) had good knowledge of palliative radiotherapy. Knowledge was correlated with self-reported knowledge (P = 0.015), discussing cases with radiation oncologist (P = 0.001), and having attended educational events on palliative radiotherapy (P = 0.001). Patient reluctance, poor performance status, and family reluctance were identified as major barriers to the use of palliative radiotherapy. Physicians from cities other than the capital were more likely to be concerned about barriers such as distance to radiotherapy facilities (P = 0.01), the duration of the referral process (P = 0.01), and the lack of a radiation oncologist available for discussing cases (P = 0.01). ConclusionsSeveral barriers affect referral to palliative radiotherapy. Some barriers seem to be more significant for physicians practicing in cities far from cancer centers. Physicians' knowledge is less than optimal and has been identified as a barrier to referral. Educational interventions and broadening the availability of cancer treatment resources are needed to improve the referral process.

Abstract C001: Palliative radiation to bony metastases from GI tumors: Disparities, outcomes, and practice patterns

Abstract PURPOSE: To evaluate the use of palliative radiotherapy (pRT) for osseous metastases among patients with gastrointestinal malignancies by sociodemographic factors, tumor type, and survival. METHODS: The NCDB was used to identify 9297 patients with GI cancers who received pRT to bony metastases from 2004 to 2013. Cancers assessed included esophageal, stomach, pancreatic, hepatocellular (HCC), bile duct &amp; other, gallbladder, colon/sigmoid, and rectal. After excluding incomplete data, 5774 remained for analysis. Strata included age, race, sex, household income, Charlson-Deyo score (CDS), site of bony metastasis, Insurance status, treatment facility type, and distance from treatment site (crow-fly). Outcomes of interest included survival after diagnosis, survival after pRT, completion of pRT, and percent of remaining life spent receiving radiotherapy (PRLSRT). Chi-squared, Kaplan Meier curve with log rank analyses, and Cox Regression evaluated outcomes as a factor of sociodemographics. RESULTS: Patients were 69% male, 81% Caucasian (CA) and 13% African American (AA). Pancreas, HCC, and Colon/Sigmoid cancers made up 63% of primary tumors. The most commonly used pRT regimen was 30Gy in 10 fractions, and single-fraction 8Gy was increasingly utilized towards 2013. As survival decreased, use of single-fraction pRT increased indicating appropriate pairing of treatment duration to prognosis. This trend was consistent among both AA and CA patients. AA patients were younger and more likely to live &amp;lt;20mi from their treatment facility compared to CA’s. AA’s were more likely to have no insurance or Medicaid (9.7% vs 5.3%, or 18.1% vs 8% p&amp;lt;0.05), and have an annual household income below $30k (37.3 vs 11.4%) compared to CA’s. AA’s were less likely to have pancreatic cancer. Slightly more AA’s completed pRT than CA’s (69.2% vs 65.2%, p&amp;lt;0.05), and had longer survival after diagnosis compared to CA (10.2 vs 9.7 months) but shorter survival after pRT suggesting a delay in palliation. Additionally, those who lived 40-60 miles from treatment facility had higher mean survival. Patients with private insurance and those treated at integrated network programs survival advantages. PRLSRT did not differ by race, but decreased from 2004 to 2013. PRLSRT&amp;gt;50% (p50) did not differ by crow-fly or facility type, but men and those with Medicare were more likely to have p50. A PRLSRT of 10% or less (p10) was more frequent in those who were treated at an academic facility, lived &amp;gt;60mi away, had private insurance, a lower CDS, or earned $48-63k/yr in 2012. Sites with more p50 were the spine, skull, and spinal cord. Sites with higher p10 were extremity, shoulder, and ribs. CONCLUSION: This study evaluated trends of pRT use among patients and stratified analyses by sociodemographic factors. Further research may uncover mechanisms of these trends and highlight potential strategies to optimize the use of pRT. Citation Format: Jason Hirshberg, Charles Hsu, Jared Robbins. Palliative radiation to bony metastases from GI tumors: Disparities, outcomes, and practice patterns [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C001.

A study to investigate whether there has been a progressive decline in the use of palliative radiotherapy for prostate cancer

A study to investigate whether there has been a progressive decline in the use of palliative radiotherapy for prostate cancer

Factors Influencing the Initiation of Strong Opioids in Cancer Patients on Palliative Care: An Audit from a Tertiary Cancer Center in India.

Aim:This audit was done to analyze the factors influencing the use of strong opioids in cancer patients receiving comprehensive palliative care from a tertiary institute.Materials and Methods:Case records of patients registered for palliative care at our center in 3 months were retrospectively reviewed and followed up throughout the course of their illness. Demographic factors, prior treatments, social support system, analgesic use at registration, and use of radiation and adjuvant analgesics were recorded. Strong opioid use and their time of initiation were evaluated, and multivariate analysis was used to identify the factors correlating with the above.Results:After registration, strong opioids were initiated in 16% of the patients. It was observed that patients younger than 55 years and those with visceral metastases and history of use of weak opioids at the time of registration had a higher probability of being started on strong opioids. Factors associated with a significantly longer strong opioid-free interval were having spouse as primary caregiver, presence of skeletal metastases, use of palliative radiotherapy, and low socioeconomic status.Conclusion:It is certain that the use of strong opioids for adequate analgesia is a necessity for palliative-care patients. However, optimal utilization of adjunctive analgesic modalities, coupled with good supportive care, can minimize the requirement and duration of strong opioid use, especially in developing countries with limited access to specialist palliative care.

Impact of positive surgical margins on secondary treatment, palliative radiotherapy and prostate cancer-specific mortality. A population-based study of 13 198 patients.

The results of studies evaluating the impact of positive surgical margins on prostate cancer-specific mortality have been inconsistent. We, therefore, evaluated the impact of surgical margin status on subsequent secondary treatment, palliative radiotherapy, and prostate cancer-specific mortality. A total of 14 837 men treated with radical prostatectomy (RP) during the period 2001 to 2015 were identified from the Cancer Registry of Norway. Of those, 13 198 (89%) patients had complete data on the preoperative prostate-specific antigen level, pathological T-category, Gleason score in the prostatectomy specimen, and margin status. Multivariable Cox proportional hazards models were used to evaluate the risk, and flexible parametric models for the cumulative incidence were fitted to predict the probabilities of secondary treatment (salvage radiotherapy or prophylactic breast radiation), palliative radiotherapy, and prostate cancer-specific mortality. After a median follow-up time of 5.2 years (3591 patients with ≥8 years of follow-up), positive surgical margins (PSMs) were independently predictive of secondary treatment (hazard ratio [HR] = 2.43, 95% confidence interval [CI] = 2.21-2.66) and palliative radiotherapy (HR = 1.45, 95% CI = 1.03-2.05). After 10 years, the absolute increased risk for palliative radiotherapy in patients with PSMs after RP varied between 0.1% in pT2 tumors with a Gleason score of 6, to 12% for pT3b tumors with a Gleason score of 9 to 10. PSMs were not independently associated with prostate cancer-specific mortality (HR = 1.14, 95% CI = 0.82-1.59). PSMs were associated with increased application of secondary treatment and palliative radiotherapy but were not predictive of prostate cancer-specific mortality. As the use of palliative radiotherapy was only marginally increased in patients with PSMs and the lowest-risk disease characteristics, avoiding PSMs may be of greatest prognostic relevance in patients with higher-risk disease characteristics.

Persistent Use of Extended Fractionation Palliative Radiotherapy for Medicare Beneficiaries With Metastatic Breast Cancer, 2011 to 2014.

With no evidence to support extended radiation courses for the palliation of bone metastases, multiple guidelines were issued discouraging its use. We assessed contemporary use and cost of prolonged palliative radiotherapy in Medicare beneficiaries with bone metastases from breast cancer. We conducted a retrospective, longitudinal study of palliative radiotherapy use among fee-for-service Medicare beneficiaries with bone metastasis from breast cancer who underwent palliative radiotherapy during 2011 to 2014. Patients were categorized according to the number of days (fractions) on which they received palliative radiotherapy: 1, 2 to 10, 11 to 19, or 20 to 30. We examined the association of clinical, demographic, and provider characteristics with the use of extended (≥11 fractions) or very extended (≥20 fractions) fractionation with logistic regression models. We also compared the cost of different fractionation schemes from the payer perspective. Of the 7547 patients in the sample (mean age, 71 y), 3084 (40.8%) received extended fractionation. The proportion of patients receiving 11 to 19 (34.7% in 2011 and 28.1% in 2014, trend P<0.001) and 20 to 30 treatments (10.3% in 2011 to 9.0% in 2014, trend P=0.07) decreased modestly over time. Patients with comorbidities were less likely to undergo extended fractionation (34.4% for ≥3 comorbidities vs. 44.9% for 0 comorbidities; adjusted odds ratio 0.67 [95% confidence interval, 0.58-0.76]). Patients treated at free-standing practices were more likely to undergo extended fractionation (47.9%) compared with those treated at hospital-based practices (37.3%, P<0.001; adjusted odds ratio, 1.49 [95% confidence interval, 1.35-1.65]). The mean cost of treatment varied from $633 (SD $240) for single-fraction treatment, to $3566 (SD $1349) for 11 to 19 fractions, to $6597 (SD $2893) for 20 to 30 fractions. The use of prolonged courses of palliative radiotherapy among Medicare beneficiaries with breast cancer remained high in 2011 to 2014. The association between free-standing facility status and use of extended fractionation suggests that provider financial incentives may impact choice of treatment.

Curative Intent Radiation Therapy Delivered Within the Last Year of Life

Use of palliative radiotherapy (pRT) within the last year of life (LYOL) has been well studied, but little is known about cancer patients that die within one year after curative-intent RT (cRT). Recently, we found that >25% cancer patients irradiated within the LYOL received cRT. Given the unexpectedly short survival, we hypothesized that many cRT patients likely had relapsed/refractory (R/R) disease at the time of RT or experienced treatment-related mortality (TRM), and we explored whether treatment intent influenced aggressiveness of care at the EOL, as measured by chemotherapy use and death in the ICU. For patients regularly seen at a single institution that died between 10/1/2014 and 9/30/2015, we extracted and linked claims data and RT records, including treatment intent by the treating radiation oncologist. Chemotherapy use and death in the ICU were based on claims, scheduling, and clinical data. R/R disease was defined as history of prior disease with recurrence and/or persistent disease despite anti-cancer therapy. Cause of death was determined based on chart review. Among 870 cancer patients, 290 were irradiated within the LYOL. Of 287 with treatment intent recorded, 101 cRT and 186 pRT patients were irradiated at a median 169 and 102 days from death, respectively. The cRT patients were younger (median 55 vs 62 years, p=0.04) with a slight male predominance (57.4%) and most frequently included patients undergoing transplant (27.7%) or with hematologic (16.8%; not undergoing transplant), head and neck (9.9%), gastrointestinal (9.9%), and sarcoma (8.9%) malignancies. Almost half (n=49, 48.5%) had R/R disease at the time of cRT; 12 had metastatic disease (11 diagnosed prior to cRT, 1 within 9 days after RT completion). The most common indications for cRT included TBI conditioning (40.8%), primary RT (32.0%), and adjuvant RT (19.4%). 11 of 103 cRT courses (10.7%) were not completed, most commonly due to intolerance of treatment. The most common cause of death was from tumor progression (n=65, 64.4%) followed by TRM (n=27, 26.7%), of which transplant and hematologic malignancy patients (n=19) made up the majority. There was no significant association between presence of R/R disease at cRT and cause of death (p=0.69). Compared with pRT patients, cRT patients had higher rates of chemotherapy use within 14 days of death (8.9% vs 2.7%, p=0.04) and ICU death (17.8% vs 3.8%, p=0.0001). Cancer patients that receive curative-intent RT in the LYOL appear to be a heterogeneous population of patients that receive more aggressive care at the EOL compared to palliatively irradiated patients. Additional studies are needed to understand how and why radiation oncologists categorize treatment as curative and whether designation of treatment as curative may influence subsequent therapies at the EOL, especially among subsets of patients with metastatic and/or R/R disease.

Persistent Use of Extended Fractionation Palliative Radiation Therapy for Medicare Beneficiaries with Metastatic Breast Cancer: 2011-2014

In response to the lack of evidence supporting extended radiotherapy fractionation for the palliative treatment of bone metastases, multiple guidelines were issued from 2011-2013 discouraging its use. We assessed contemporary use and cost implications of prolonged treatment course in a sample of Medicare beneficiaries with breast cancer who received palliative radiotherapy for bone metastases. We conducted a retrospective, longitudinal study of palliative radiotherapy use among fee for service Medicare beneficiaries, using the Chronic Condition Warehouse (CCW) database. We used ICD-9 diagnosis and procedure codes to identify women with breast cancer bone metastasis who underwent palliative radiotherapy during 2011-2014. Patients were then categorized according to the number of days (‘fractions’) on which they received palliative radiotherapy: 1, 2-10, 11-19, or 20-30. We analyzed the association between patient clinical and demographic characteristics, provider characteristics, and the use of extended fractionation (defined as 11 or more fractions). We compared treatment cost associated with the different fractionation schemes. All costs were inflation adjusted to 201x U.S. dollars. Of the 7,547 patients in the sample (mean age 71 years), 3,084 (41%) received at least 11 fractions. The proportion of patients receiving 11-19 (34.7% in 2011 and 28.1% in 2014) and 20-30 treatments (10.3% in 2011 to 9.0% in 2014) decreased modestly over time, but remained persistently high. Patients with more comorbidities (>2 comorbidities vs. 0 comorbidities) were less likely to undergo extended fractionation (adjusted odds ratio [AOR] 0.67 [95%CI 0.58-0.76]). Patients treated at freestanding practices were more likely to undergo extended fractionation compared to those treated at hospital-based practices (70.0% vs. 30.0%, p<.001; AOR 1.42 [95% CI 1.27-1.60]). The mean cost of treatment varied from $6,597 [Standard deviation (SD) $2,893] for 20-30 fractions, to $3,566 [SD $1,349] for 11-19 fractions, and $633 [SD $240] for single fraction treatment. The use of prolonged course palliative radiotherapy among Medicare beneficiaries with breast cancer remained persistently high in 2011-2014, despite lack of evidence for its clinical benefit and higher costs in comparison to shorter course treatment. The association between freestanding facility status and use of extended fractionation suggests that provider financial incentives may impact choice of treatment.