Medical Technology

End-of-life patients continue using radiotherapy in a harmful manner

A comprehensive national database study found that radiotherapy is still used in patients suffering from metastatic disease who are near the end of their lives. The authors state that this underscores the importance of following the guidelines.

The study was published online on January 14, 2014 in JAMA Health Forum.

“No patient should be forced into prolonged or prolonged treatments that aren’t based on scientific evidence.” Patricia Santos, MD as lead author from the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, stated Medscape Medical News via email.

“Given that patients at the end of their lives are among the most vulnerable patients, it should concern practitioners that extended radiotherapy is very common in this group,” she added.

Sloan Kettering’s senior author Erin Gillespie, MD, shared her opinion. “Our findings should matter for both doctors and patients alike because overtreatment or unnecessary treatment of any kind could increase the risk of harm can occur, without the proof of benefit.”

“And stakes are arguably highest for patients with metastatic cancer, for whom quality not quantityof life is our main goal,” Gillespie emphasized. She noted that the study results emphasize “the necessity of not providing extended treatments to patients, as some will invariably spend a large amount of money on treatment.”

Guideline-Nonconcordant Radiotherapy

The study only included patients over 65 who died within 90 days of the time frame for treatment planning.

The primary outcome was guideline-nonconcordant radiotherapy, the authors note. Santos explained radiotherapy could be considered nonconcordant if more that 10 fractions were employed or when radiation was administered using a method that was not approved by the American Society of Radiation Oncology.

As part of the Making the Right Choice campaign, ASTRO has broadly stated that doctors shouldn’t routinely employ extended fractionation schemes for palliation of bone metastases or routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery to treat only a few brain metastases..

The study team looked at 467,781 radiotherapy sessions.

Half of these patients used radiotherapy to treat brain or bone metastases (9.2 percent bone metastases, 5.8% brain metastases).

A total of 3.7 percent of the patients died within 90 days of radiotherapy about half of them died of bone metastases and the remaining half died of brain metastases.

Of the patients who died within 90 days of receiving radiotherapy, 78.4% received guideline-concordant radiotherapy but the other 21.6% received guideline-nonconcordant radiotherapy, the authors report.

On multivariate analysis, patients who were treated in a hospital-affiliated facility were half as likely to receive guideline-nonconcordant radiotherapy at an adjusted odds ratio (aOR) of 0.50.

Older patients between age 75-85 years were 10% less likely to receive guideline-nonconcordant radiotherapy at an aOR of 0.90, they add, while patients 85 years of age and older were 27% less likely to receive guideline-nonconcordant radiotherapy at an aOR of 0.73. Both age groups were being compared to patients between 65 and 75 years of age.

Conversely, patients who had undergone a major procedure were 17% more likely to receive guideline-nonconcordant radiotherapy, while those who had received chemotherapy were 26% more like to receive the same inappropriate treatment.

Interestingly, patients who were expected to survive for more than 30 days after the treatment planning appointment were at greatest risk to receive guideline-nonconcordant therapy, the investigators point out.

For example, patients whose survival was projected to last for up to 60 days after the treatment planning appointment were almost five times as likely to receive guideline-nonconcordant radiotherapy at an aOR of 4.72. Those who were projected to survive up to 90 days after the treatment planning appointment were almost 7 times more likely to receive guideline-nonconcordant radiotherapy at an aOR of 6.55. Both groups were being compared with patients who were not expected to last beyond 30 days ( P <.001 for both endpoints).

“In general, our findings revealed that the odds of receiving nonguideline concordant radiation were more likely if a patient remained alive for more than 30 days after treatment,” Santos acknowledged. “This probably speaks to the fact that patients who are thought to have a better chance of survival are typically given more aggressive treatment,” she added.

The problem with this thinking, as Santos pointed out, is that the prognosis can be very difficult to assess in patients suffering from metastatic disease, particularly when the cancer has moved into the bone and the brain.

Although the claims data analyzed in this study didn’t allow investigators to assess performance status at the time of treatment, “our guiding principle was that the guidelines generally apply to all patients regardless of prognosis” she stated.

Furthermore, the fact remains, Santos noted, that the purpose of treatment for each patient can be dynamic at least on treatment initiation; if that goal moves toward improving the chances of survival, “treating a patient with definitive or palliative intent could dramatically alter the way in how radiation is administered.”

This issue could be solved by involving palliative or supportive care services earlier in a patient’s treatment process, as involving these services early may minimize the chance of overtreatment, Santos suggested.

Gillespie reports receiving funding from the National Cancer Care Network/Pfizer EMBRACE and was co-founder of a website for education for radiation oncology professionals (eContour.org). Other disclosures were not disclosed.

JAMA Health Forum. Published online January 14 2022. Abstract

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