An Analysis of Clinical and Systemic Factors Associated with Palliative Radiotherapy Delivery and Completion at the End of Life in Alberta, Canada

Abstract

Radiotherapy (RT) is often utilized for symptom control at the end of life. Palliative RT (pRT) may not be taken to completion by patients, thus decreasing clinical benefits and adversely impacting resource allocation. We determined rates of incomplete pRT and examined predictors of non-completion using an electronic questionnaire. Methods: A questionnaire was embedded within the RT electronic prescribing system for all five cancer centers of Alberta, Canada, between 2017 and 2020. Prescribing radiation oncologists (ROs) were tasked with completing the questionnaire. Treatment variables were collected for 2040 patients prescribed pRT. Details on pRT courses delivered and completed were used to determine rates of incomplete RT. Electronic medical records of a subset of 367 patients randomly selected from the 2040 patients were then analyzed to examine for association of non-completion of RT with patient, disease, and therapy-related factors. Results: Overall, 10% of patients did not complete pRT. The rate of single fractions prescribed as a proportion of all RT fractions increased from 18% (pre-2017: pre-study era) to 29% (2017–2020: study era) (p < 0.0001). After conducting multivariate analysis on the overall group, multiple lifetime malignancies (OR:0.64) or increasing the number of pRT fractions (OR:0.08–0.17) were associated with non-completion. Being selected for stereotactic RT (OR:3.75) or survival > 30 days post-RT prescription (OR:2.20–5.02) were associated with greater rates of RT completion. The ROs’ estimates of life expectancy at the time of RT prescription were not predictive of RT completion. In the multivariate analysis of the 367-patient subset, the presence of hepatic metastases (OR 2.59), survival 30–59 days (OR 6.61) and survival 90+ days (OR 8.18) post-RT prescription were associated with pRT completion. Only increasing pRT fractionation (OR:0.05–0.2) was associated with non-completion. Conclusion: One in ten patients prescribed pRT did not complete their treatment course. Decreasing pRT fractionation and improving prognostication in patients near the end of life may decrease rates of incomplete RT courses.

A Systematic Review of Prognostic Factors in Patients with Cancer Receiving Palliative Radiotherapy: Evidence-Based Recommendations

“…We observed that in select situations, such as recurrent disease, brain metastases, and spinal cord compression, there is some evidence to guide who may be suitable for retreatment or SBRT based on their life expectancy ( [11,19,22,28,31,32,34,35,38,39,43,44] and [12] (p. 20)). Patients with a longer predicted survival are generally more suitable for longer courses of PRT, as they are more likely to complete their treatment [45]. The use of SBRT, as demonstrated in SC24 [46], is thus likely more appropriate in patients with longer predicted survivals as well.…”

“…Other studies have examined how to utilize prognostication in more generalized populations with advanced cancers [2]. Studies have shown that up to 10% of patients prescribed PRT do not complete their treatment course [44,45]. Better prognostication and a more judicious selection of who may benefit from PRT should improve QoL for patients and resource utilization in departments with constrained resources.…”