Appropriateness of the 30-day expected mortality metric in palliative radiation treatment: a narrative review

Abstract

Background and Objective: The 30-day expected mortality rate is frequently used as a metric to determine which patients benefit from palliative radiation treatment (RT). We conducted a narrative review to examine whether its use as a metric might be appropriate for patient selection.Methods: A literature review was conducted to identify relevant studies that highlight the benefits of palliative RT in timely symptom management among patients with a poor performance status, the accuracy of predicting survival near the end of life and ways to speed up the process of RT administration through rapid response clinics.Key Content and Findings: Several trials have demonstrated substantial response rates for pain and/or bleeding by four weeks and sometimes within the first two weeks after RT. Models of patient survival have limited accuracy, particularly for predicting whether patients will die within the next 30 days. Dedicated Rapid Access Palliative RT (RAPRT) clinics, in which patients are assessed, simulated and treated on the same day, reduce the number of patient visits to the radiation oncology department and hence the burden on the patient as well as costs.^ ORCID: 0000-0001-7347-2461.Conclusions: Single-fraction palliative RT should be offered to eligible patients if they are able to attend treatment and could potentially benefit from symptom palliation, irrespective of predicted life expectancy.We discourage the routine use of the 30-day mortality as the only metric to decide whether to offer RT.More common implementation of RAPRT clinics could result in a significant benefit for patients of all life expectancies, but particularly those having short ones.

Utility of 30‐day mortality as a quality metric for palliative radiation treatment: A population‐based analysis from Queensland, Australia

“…While there is evidence to support using 30 day mortality following PRT as a quality metric for centres, it remains that for some patients, single fraction PRT within 30 days of death will be appropriate to palliate pain or bleeding. This has been discussed in depth in a narrative review by Navarro‐Domenech et al 29 . and case by case appropriateness of treatment can be easily evaluated in individual centres within morbidity and mortality meetings.…”

Audit of 30-day mortality following palliative radiotherapy: Are we able to improve patient care at the end of life?

“…Because these models have limited accuracy, particularly for predicting whether patients will die within the next 30 days, some authors have discouraged the routine use of the 30-DM as the only metric to decide whether to offer PRT, particularly in painful bone metastases, spinal cord compression and hemostatic treatments. For these indications, several trials have demonstrated substantial response rates by four weeks and sometimes within the first two weeks after PRT [ 33 ].…”

Palliative radiation therapy: Can we do better?

“…It is generally considered that such patients are unlikely to benefit from palliative RT before succumbing, although a recent review from international experts questions this assumption when the measure is used predictively ('expected' 30-day mortality). 5 A 2022 meta-analysis found an overall (retrospective) 30-day mortality rate of 16% (95% CI = 14-18%), proposed as a baseline for future comparisons between individual centres. However, not surprisingly, sub-group analysis did identify various factors resulting in higher mortality (e.g.…”