Palliative radiotherapy near the end of life

Susan Y Wu, Lisa Singer, Lauren Boreta, Michael A Garcia, Shannon E Fogh, Steve E Braunstein, Susan Y Wu, Lisa Singer, Lauren Boreta, Michael A Garcia, Shannon E Fogh, Steve E Braunstein

Abstract

Background: A significant proportion of patients with advanced cancer undergo palliative radiotherapy (RT) within their last 30 days of life. This study characterizes palliative RT at our institution and aims to identify patients who may experience limited benefit from RT due to imminent mortality.

Methods: Five hundred and-eighteen patients treated with external beam RT to a site of metastatic disease between 2012 and 2016 were included. Mann-Whitney U and chi-squared tests were used to identify factors associated with RT within 30 days of death (D30RT).

Results: Median age at RT was 63 years (IQR 54-71). Median time from RT to death was 74 days (IQR 33-174). One hundred and twenty-five patients (24%) died within 30 days of RT. D30RT was associated with older age at RT (64 vs. 62 years, p = 0.04), shorter interval since diagnosis (14 vs. 31 months, p < 0.001), liver metastasis (p = 0.02), lower KPS (50 vs. 70, p < 0.001), lower BMI (22 vs. 24, p = 0.001), and inpatient status at consult (56% vs. 26%, p < 0.001). Patients who died within 30 days of RT were less likely to have hospice involved in their care (44% vs. 71%, p = 0.001). D30RT was associated with higher Chow and TEACHH scores at consult (p < 0.001 for both).

Conclusions: Twenty-four percent of patients received palliative RT within 30 days of death. Additional tools are necessary to help physicians identify patients who would benefit from short treatment courses or alternative interventions to maximize quality at the end of life.

Keywords: Cancer; End-of-life care; Palliative radiotherapy.

Conflict of interest statement

Ethics approval and consent to participate

This retrospective review was approved by the UCSF institutional review board (CHR 15–17,608).

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Chow E, Zeng L, Salvo N, Dennis K, Tsao M, Lutz S. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol) 2012;24(2):112–124. doi: 10.1016/j.clon.2011.11.004.
    1. McDonald R, Ding K, Brundage M, Meyer RM, Nabid A, Chabot P, et al. Effect of radiotherapy on painful bone metastases: a secondary analysis of the NCIC clinical trials group symptom control trial SC.23. JAMA Oncol. 2017;3(7):953–959. doi: 10.1001/jamaoncol.2016.6770.
    1. van der Linden YM, Lok JJ, Steenland E, Martijn H, van Houwelingen H, Marijnen CAM, et al. Single fraction radiotherapy is efficacious: a further analysis of the Dutch bone metastasis study controlling for the influence of retreatment. IJROBP. 2004;59(2):528–537.
    1. Dennis K, Wong K, Zhang L, Culleton S, Nguyen J, Holden L, et al. Palliative radiotherapy for bone metastases in the last 3 months of life: worthwhile or futile? Clin Oncol. 2011;23(10):709–715. doi: 10.1016/j.clon.2011.05.004.
    1. Bezjak A, Adam J, Barton R, Panzarella T, Laperriere N, Wong CS, et al. Symptom response after palliative radiotherapy for patients with brain metastases. Eur J Cancer. 2002;38(4):487–496. doi: 10.1016/S0959-8049(01)00150-2.
    1. Chow E, Davis L, Holden L, Tsao M, Danjoux C. Prospective assessment of patient-rated symptoms following whole brain radiotherapy for brain metastases. J Pain Symptom Manag. 2005;30(1):18–23. doi: 10.1016/j.jpainsymman.2005.02.009.
    1. Mulvenna P, Nankivell M, Barton R, Faivre-Finn C, Wilson P, McColl E, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet. 2016;388(10055):2004–2014. doi: 10.1016/S0140-6736(16)30825-X.
    1. Gripp S, Mjartan S, Boelke E, Willers R. Palliative radiotherapy tailored to life expectancy in end-stage cancer patients. Cancer. 2010;116(13):3251–3256. doi: 10.1002/cncr.25112.
    1. Guadagnolo BA, Liao K-P, Elting L, Giordano S, Buchholz TA, Shih Y-CT. Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States. J Clin Oncol. 2013;31(1):80–87. doi: 10.1200/JCO.2012.45.0585.
    1. Ellsworth SG, Alcorn SR, Hales RK, McNutt TR, DeWeese TL, Smith TJ. Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution. Int J Radiat Oncol Biol Phys. 2014;89(5):1100–1105. doi: 10.1016/j.ijrobp.2014.04.028.
    1. Dewys WD, Begg C, Lavin PT, Band PR, Bennett JM, Bertino JR, et al. Prognostic effect of weight loss prior tochemotherapy in cancer patients. Am J Med. 1980;69(4):491–497. doi: 10.1016/S0149-2918(05)80001-3.
    1. Krishnan MS, Epstein-Peterson Z, Chen Y-H, Tseng YD, Wright AA, Temel JS, et al. Predicting life expectancy in patients with metastatic cancer receiving palliative radiotherapy: the TEACHH model. Cancer. 2013;120(1):134–141. doi: 10.1002/cncr.28408.
    1. Chow E, Abdolell M, Panzarella T, Harris K, Bezjak A, Warde P, et al. Predictive model for survival in patients with advanced Cancer. J Clin Oncol. 2008;26(36):5863–5869. doi: 10.1200/JCO.2008.17.1363.
    1. Loscalzo J, Calves P, Kao J. The NEAT Predictive Model for Survival in Patients with Advanced Cancer. Cancer Res Treat. 2018;50(4):1433–43.
    1. Tiwana MS, Barnes M, Kiraly A, Olson RA. Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort. BMC Palliat Care. 2016;15(1):2. doi: 10.1186/s12904-015-0072-5.
    1. Tseng YD, Gouwens NW, Lo SS, Halasz LM, Spady P, Mezheritsky I, et al. Use of radiation therapy within the last year of life among Cancer patients. Int J Radiat Oncol Biol Phys. 2018;101(1):21–29. doi: 10.1016/j.ijrobp.2018.01.056.
    1. Park KR, Lee CG, Tseng YD, Liao JJ, Reddy S, Bruera E, et al. Palliative radiation therapy in the last 30 days of life: a systematic review. Radiother Oncol. 2017;125(2):193–199. doi: 10.1016/j.radonc.2017.09.016.
    1. Kapadia NS, Mamet R, Zornosa C, Niland JC, D'Amico TA, Hayman JA. Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer. Cancer. 2012;118(17):4339–4345. doi: 10.1002/cncr.27401.
    1. Murphy JD, Nelson LM, Chang DT, Mell LK, Le Q-T. Patterns of Care in Palliative Radiotherapy: a population-based study. J Oncol Pract. 2013;9(5):e220–e227. doi: 10.1200/JOP.2012.000835.
    1. Ryoo JJ, Batech M, Zheng C, Kim RW, Gould MK, Kagan AR, et al. Radiotherapy for brain metastases near the end of life in an integrated health care system. Ann Palliat Med. 2017;6(Suppl 1):S28–S38. doi: 10.21037/apm.2017.03.04.
    1. Toole M, Lutz S, Johnstone PAS. Radiation oncology quality: aggressiveness of cancer care near the end of life. J Am Coll Radiol. 2012;9(3):199–202. doi: 10.1016/j.jacr.2011.11.006.
    1. Gripp S, Moeller S, Bölke E, Schmitt G, Matuschek C, Asgari S, et al. Survival prediction in terminally ill cancer patients by clinical estimates, laboratory tests, and self-rated anxiety and depression. J Clin Oncol. 2007;25(22):3313–3320. doi: 10.1200/JCO.2006.10.5411.
    1. Chow E, Davis L, Panzarella T, Hayter C, Szumacher E, Loblaw A, et al. Accuracy of survival prediction by palliative radiation oncologists. Int J Radiat Oncol Biol Phys. 2005;61(3):870–873. doi: 10.1016/j.ijrobp.2004.07.697.
    1. Morita T, Tsunoda J, Inoue S, Chihara S. Improved accuracy of physicians’ survival prediction for terminally ill cancer patients using the palliative prognostic index. Palliat Med. 2016;15(5):419–424. doi: 10.1191/026921601680419474.
    1. Subramaniam S, Thorns A, Ridout M, Thirukkumaran T, Osborne TR. Accuracy of prognosis prediction by PPI in hospice inpatients with cancer: a multi-Centre prospective study. BMJ Support Palliat Care. 2015;5(4):399–404. doi: 10.1136/bmjspcare-2012-000239rep.
    1. Maltoni M, Scarpi E, Pittureri C, Martini F, Montanari L, Amaducci E, et al. Prospective comparison of prognostic scores in palliative care cancer populations. Oncologist. 2012;17(3):446–454. doi: 10.1634/theoncologist.2011-0397.
    1. Feliu J, Jiménez-Gordo AM, Madero R, Rodríguez-Aizcorbe JR, Espinosa E, Castro J, et al. Development and validation of a prognostic nomogram for terminally ill cancer patients. J Natl Cancer Inst. 2011;103(21):1613–1620. doi: 10.1093/jnci/djr388.
    1. Bekelman JE, Epstein AJ, Emanuel EJ. Single- vs multiple-fraction radiotherapy for bone metastases from prostate Cancer. JAMA. 2013;310(14):1501–1502. doi: 10.1001/jama.2013.277081.
    1. Hartsell WF, Scott CB, Bruner DW, Scarantino CW, Ivker RA, Roach M, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97(11):798–804. doi: 10.1093/jnci/dji139.
    1. JS-Y W, Wong R, Johnston M, Bezjak A, Whelan T. Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys. 2003;55(3):594–605. doi: 10.1016/S0360-3016(02)04147-0.
    1. Westhoff PG, Verdam MGE, Oort FJ, Jobsen JJ, van Vulpen M, Leer JWH, et al. Course of quality of life after radiation therapy for painful bone metastases: a detailed analysis from the Dutch bone metastasis study. Int J Radiat Oncol Biol Phys. 2016;95(5):1391–1398. doi: 10.1016/j.ijrobp.2016.03.032.
    1. Rades D, Lange M, Veninga T, Stalpers LJA, Bajrovic A, Adamietz IA, et al. Final results of a prospective study comparing the local control of short-course and long-course radiotherapy for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys. 2011;79(2):524–530. doi: 10.1016/j.ijrobp.2009.10.073.
    1. Tsao MN, Rades D, Wirth A, Lo SS, Danielson BL, Gaspar LE, et al. Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): an American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol. 2012;2(3):210–225. doi: 10.1016/j.prro.2011.12.004.
    1. Fairchild A, Barnes E, Ghosh S, Ben-Josef E, Roos D, Hartsell W, et al. International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice? Int J Radiat Oncol Biol Phys. 2009;75(5):1501–1510. doi: 10.1016/j.ijrobp.2008.12.084.
    1. Moghanaki D, Cheuk AV, Fosmire H, Anscher MS, Lutz ST, Hagan MP, et al. Availability of single-fraction palliative radiotherapy for cancer patients receiving end-of-life care within the veterans healthcare administration. J Palliat Med. 2014;17(11):1221–1225. doi: 10.1089/jpm.2014.0041.
    1. Guadagnolo BA, Liao K-P, Giordano SH, Elting LS, Buchholz TA, Y-CT S. Increasing use of advanced radiation therapy technologies in the last 30 days of life among patients dying as a result of cancer in the United States. J Oncol Pract. 2014;10(4):e269–e276. doi: 10.1200/JOP.2013.001348.
    1. Dans M, Smith T, Back A, Baker JN, Bauman JR, Beck AC, et al. NCCN guidelines insights: palliative care, version 2. J Natl Compr Canc Netw. 2017;15:989–997. doi: 10.6004/jnccn.2017.0132.
    1. World Health Organization Strengthening of palliative care as a component of integrated treatment throughout the life course. J Pain Palliat Care Pharmacother. 2014;28(2):130–134. doi: 10.3109/15360288.2014.911801.
    1. Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, et al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017;35:96–112. doi: 10.1200/JCO.2016.70.1474.
    1. Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741–749. doi: 10.1001/jama.2009.1198.
    1. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–742. doi: 10.1056/NEJMoa1000678.
    1. Quill TE, Abernethy AP. Generalist plus specialist palliative care--creating a more sustainable model. N Engl J Med. 2013;368(13):1173–1175. doi: 10.1056/NEJMp1215620.
    1. Murray SA, Kendall M, Mitchell G, Moine S, Amblàs-Novellas J, Boyd K. Palliative care from diagnosis to death. BMJ. 2017;27:j878. doi: 10.1136/bmj.j878.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe