Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer

Abstract

BACKGROUND:Receipt of chemotherapy at the end of life (EOL) is considered an indicator of poor quality of care for medical oncology. The objective of this study was to characterize the use of radiotherapy (RT) in patients with nonsmall cell lung cancer (NSCLC) during the same period.METHODS:Treatment characteristics of patients with incurable NSCLC who received RT at the EOL, defined as within 14 days of death, were analyzed from the National Comprehensive Cancer Network NSCLC Outcomes Database.RESULTS:Among 1098 patients who died, 10% had received EOL RT. Patients who did and did not receive EOL RT were similar in terms of sex, race, comorbid disease, and Eastern Cooperative Oncology Group performance status. On multivariable logistic regression analysis, independent predictors of receiving EOL RT included stage IV disease (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.09‐3.83) or multiorgan involvement (OR, 1.75; 95% CI, 1.08‐2.84) at diagnosis, age <65 years at diagnosis (OR, 1.85; 95% CI, 1.21‐2.83), and treating institution (OR, 1.24‐5.94; P = .02). Nearly 50% of EOL RT recipients did not complete it, most commonly because of death or patient preference.CONCLUSIONS:In general, EOL RT was received infrequently, was delivered more commonly to younger patients with more advanced disease, and often was not completed as planned. There also was considerable variation in its use among National Comprehensive Cancer Network institutions. Next steps include expanding this research to other cancers and settings and investigating the clinical benefit of such treatment. Cancer 2012. © 2012 American Cancer Society.

Assessment of National Practice for Palliative Radiation Therapy for Bone Metastases Suggests Marked Underutilization of Single-Fraction Regimens in the United States

“…High-quality, high-value care in the patient with metastatic disease in particular is defined by an emphasis on minimization of time spent in the medical setting receiving treatment, which affords an improvement in quality of life (30,42). However, many patients receive radiation therapy near the end of life owing to its efficacy in diminishing pain from osseous metastases and because of the uncertain art of prognostication (15,28,43,44). Although palliative treatment to bone metastases near the end of life will likely continue, more valueconscious and patient-centered care would be reflected by an increase in the proportion of patients receiving SF-RT in the United States.…”

Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists

“…While palliative radiotherapy undoubtedly benefits patients with cancer in various stages of the disease, in terms of improving symptoms and potentially prolonging survival, its use during the last month of life has recently been questioned (5)(6)(7). Clinicians are often excessively optimistic when estimating the life expectancy of patients with advanced cancer, which may lead to treatment decisions that eventually become a burden for patients and caregivers, without improving the quality of life of the patients during the terminal phase of the disease (8,9).…”

Trend in and Correlates of Undergoing Radiotherapy in Taiwanese Cancer Patients' Last Month of Life

“…[19][20][21] No population-based studies investigated EOL radiotherapy for all ages, disease groups, and geographic areas. Among these studies, only five 3,9,11,18,21 targeted radiotherapy within patients' last month of life-a critical period proposed for evaluating aggressiveness of EOL care. 22 Furthermore, these studies did not comprehensively consider patient, physician, hospital, and regional factors suggested as a conceptual framework to determine treatment intensity for seriously ill patients.…”

“…14 Better understanding the factors predisposing cancer patients to receive EOL radiotherapy can guide development of interventions that strike a balance between the benefits of radiotherapy and burdens on patients and societal resources, thus controlling the skyrocketing costs of cancer M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT 5 5 care. 14 However, the few studies investigating radiotherapy within patients' last 1-2 years for all indications (excluding for bone metastasis only) have focused on elderly patients 3,11,15 and limited cancers (i.e., lung, 3,11,[15][16][17] breast, 3,11,15,18 prostate 3,11,15 and colorectal 3,11,15 ), institutes, 9,16 or geographical areas. [19][20][21] No population-based studies investigated EOL radiotherapy for all ages, disease groups, and geographic areas.…”

“…2,5 A significant proportion of terminally ill patients undergoes radiotherapy that may be inappropriately tailored to their illness trajectory and evidence-based guidelines, i.e., lengthy multi-fractionated therapy, 2,5,7,8 resulting in patients dying during/shortly after treatment, 3,5,7 and treatment being prematurely terminated without symptom improvement 5,7,10 because of patient decline. 5,7,9 Furthermore, more patients who received radiotherapy in the last month of life had emergency room visits or hospitalizations, longer hospitalizations, intensive care unit (ICU) admission, and higher health care costs than those without radiotherapy before death. 11 Radiotherapy at EOL (EOL radiotherapy) has shifted toward more advanced, resource-intensive techniques, 12 further increasing radiotherapy costs 13 that outpace growth in other sectors of health care expenditures.…”