Impact of Radiation Therapy on Aggressive Care and Quality of Life Near Death

Abstract

Context Radiation therapy (RT) is used with palliative intent in patients with advanced stage cancer. Prior studies, primarily in patients with poor performance status (PS), suggest that RT is associated with aggressive medical care, which may impact patients’ quality of life near death (QoD) adversely. Objective This study examines associations between RT use and patients’ receipt of aggressive care and QoD based on patients’ PS. Methods Multi-institutional, prospective cohort study of patients with end-stage cancers (N=312) and identified as terminally ill at study enrollment. RT use (n=24; 7.7%) and Eastern Cooperative Oncology Group (ECOG) PS were assessed at study entry (median = 3.8 months before death). Aggressive care near death was operationalized as use of mechanical ventilation and/or resuscitation in the last week of life. QoD was determined using validated caregiver ratings of patients’ physical and mental distress in their final week. Results RT use was associated with higher QoD (8/8, 100.0%, versus 58/114, 50.9%; p=0.006) among patients with good PS (ECOG=1), more aggressive care near death (3/9, 33.3%, versus 6/107, 5.6%; p=0.020) among patients with moderate PS (ECOG=2), and lower QoD (1/7, 14.3%, versus 28/51, 54.9%; p=0.046) among patients with poor PS (ECOG=3). Conclusions Targeted use of RT in end-of-life cancer care may benefit patients with good PS, but its use may adversely affect patients with poorer PS. Decisions about RT use in this setting should consider likely end-of-life outcomes based on patients’ current PS.

Reply to Serin et al.

“…6,14 Palliative RT takes weeks to months to take effect, 15 and yields the most benefit when delivered early during the disease trajectory, when patients live long enough to benefit. Administered appropriately, RT can reduce pain, shrink tumors and even, as we found in our study, 1 improve overall quality of life in patients with advanced cancer. However, when RT is administered close to death in patients with poor performance status, we find it lacks efficacy, 1 consistent with studies demonstrating that approximately 50% of patients experiencing worsening symptoms despite treatment.…”

“…Administered appropriately, RT can reduce pain, shrink tumors and even, as we found in our study, 1 improve overall quality of life in patients with advanced cancer. However, when RT is administered close to death in patients with poor performance status, we find it lacks efficacy, 1 consistent with studies demonstrating that approximately 50% of patients experiencing worsening symptoms despite treatment. 16 Though shorter course regimens may have need for retreatment, this is likely not a relevant consideration in patients with short life expectancy, who will not live long enough to experience recurrence of pain.…”

“…We thank Serin et al for their probing questions about our study 1 and appreciate this opportunity to respond and to clarify our results. We agree that age is an important consideration, as associated comorbidities and physiology may impact functional reserve and, potentially, tolerance to radiation therapy (RT).…”

Metastatic Osseous Pain Control: Radiation Therapy

“…2), but not patients with poor performance status. 30 Moving forward, trials incorporating patient-reported outcome measures in conjunction with clinical outcomes are warranted to provide high-quality data to help direct the use of PRT.…”

The challenge of sustainability in healthcare systems: cost of radiotherapy in the last month of life in an Italian cancer center

“…The quality of care delivered to cancer patients near the end of life (EOL) has become a hot topic for researchers [1][2][3][4][5][6][7][8][9][10][11][12][13][14] and is contributing to the development of interventions and policies to guarantee appropriate EOL care and to optimize the use of healthcare resources [2,6,7,10,15,16]. Little information is available on the correlation between EOL care and healthcare costs, the majority of economic evaluations having been conducted in the USA [1,5,11] whose healthcare system differs significantly from most of the European ones. However, all the studies agree that reducing EOL costs represents a constant challenge within the healthcare system [9,10].…”