Palliative radiation therapy (PRT) is an effective treatment to reduce pain and the debilitating effects of advanced, incurable cancer. Yet, it may require lengthy hospital stays, and side effects from radiation may outweigh the benefits. Determining the appropriateness of PRT is best managed by oncology, radiation oncology, and palliative care specialists working with patients and their families/caregivers.
A PRT consulting service was established at Mount Sinai Hospital in New York City to facilitate shared decision-making. Its contributions—more informed clinical decisions and cost reductions—are described in the April issue of the Journal of Pain Management and the June issue of the Journal of Pain and Symptom Management.1,2
The Palliative Radiation Oncology Consult (PROC) service was established in October 2013 to improve the quality of palliative care for both inpatients and outpatients. Its clinical staff includes a radiation oncologist specializing in PRT, a nurse, and rotating residents and fellows. One or more representatives of the PROC team attend tumor boards and routinely participate in family meetings.
Applied Radiation Oncology talked with Kavita Dharmarajan, MD, (pictured above) assistant professor of radiation oncology, geriatrics and palliative medicine at Mount Sinai. A specialist in PRT, and head of the PROC service, Dr. Dharmarajan leads the palliative oncology tumor board, which is attended by representatives of medical oncology, interventional radiology, palliative care, pain/anesthesia, and social work. It is a forum where the most difficult cases are discussed with respect to unsuccessful pain treatment methods and/or where repeat radiation therapy is being considered.
“PROC staff are often involved in goals-of-care conversations, especially for hospitalized patients,” says Dr. Dharmarajan. “We try to expedite consultation for, and initiation of, radiation treatment as much as possible.”
The PROC has also created a partnership with a local hospice agency, which has enabled some hospice patients to receive PRT while maintaining their hospice status. “This is a humanitarian benefit to the patient and may also allow the patient to receive the benefits of hospice while receiving cancer-directed therapy in the form of palliative radiation,” she says.
“The existence of PROC enables the radiation therapy physicians and staff to be better informed on a patient’s condition and ability to tolerate PRT,” adds Dr. Dharmarajan, noting that the PROC team educates patients, families and caregivers about the treatment, enabling them to more fully grasp reasonable expectations of treatment. “This often leads to better informed decisions that are well-matched with their needs. We think we see the value of the PROC service by the fact that referrals to us have increased significantly over the last several years.”
Dr. Dharmarajan and colleagues conducted an observational cohort study to formally assess the impact of PROC on clinical and healthcare utilization outcomes among advanced cancer patients. Their study cohort included patients who underwent PRT for symptomatic bone metastases at Mount Sinai Hospital between December 2009 and February 2017. The study included 154 patients who received PRT before, and 296 after, PROC was established. The researchers compared and analyzed changes in PRT course planning and completion, pain improvement, hospital length of stay (LOS), and utilization of palliative care services. Treatment was categorized into four groups by number of fractions, and comparisons were balanced on relevant covariates covering demographic and clinical factors.
The study showed that patients in the post-PROC group were slightly more likely to complete their course of treatment than the pre-PROC group (92% compared to 86%). The authors attributed this to greater use of shorter, more efficient radiation treatment regimens. This has the ripple effect of more patients completing their prescribed radiation therapy treatment and spending fewer days in the hospital.
While the majority of patients in both cohorts had pain improvement at one-month follow-up after PRT (73.2% pre-PROC vs. 79.2% post-PROC), the difference in pain improvement rates was not statistically significant. The duration of hospital stays for inpatients was shorter by about 5 days for inpatients in the post-PROC cohort. Importantly, patient referrals to radiation oncologists for PRT nearly doubled with the availability of PROC (296 patients compared to 154 patients).
An analysis of total hospitalization cost of 76 inpatients in the pre-PROC group and 105 in the post-PROC group revealed an average cost savings of $20,719 for the latter. Costs were standardized to 2016 dollars, and included radiology imaging, medications, radiation oncology, laboratory tests, specialty consultations, and room and board. The median total hospitalization cost was $76,792 for patients treated before PROC and $50,582 after PROC. PROC was associated with shorter PRT schedules, increased palliative care utilization, and an 8.5-day reduction in hospital stay.
The authors also noted that specialist-level palliative care consultations were significantly more common in the post-PROC cohort. They attributed this to routine referral by the PROC team for additional management of symptom controls and goals-of-care planning. “Reduction of costs observed in our investigation was, therefore, likely multifactorial, resulting from a synergistic effect of increased generalist-level and specialty-level palliative care utilization that led to improved symptom management, more timely goals-of-care planning before initiation of radiation therapy, greater usage of shorter radiation regimens in appropriate patients and, consequently, reduced length of hospital stay,” they wrote.2
Dr. Dharmarajan explained that before PROC was established, oncologists in the health system may not have routinely considered PRT for patients as much as they do now. She attributes this to many patients being prescribed lengthier radiation regimens in the pre-PROC era and often not receiving simultaneous chemotherapy because the combined effect on toxicity could potentially be too great. This possible increase could, in turn, occasionally prompt disease progression in other areas of a patient’s body while undergoing radiation therapy.
“Oncologists who previously were concerned about keeping a patient off chemo for several weeks in a row are now less worried about the potentially detrimental consequences of that. The PRT regimens we utilize are usually shorter now, so breaks in chemotherapy are also shorter,” she says. “My colleagues and I are also more mindful that chemotherapy breaks can be deleterious. Sometimes we are comfortable even giving radiation during certain chemotherapy regimens, whereas before we were not as comfortable.”
To combat underutilization of PRT at other hospitals, Dr. Dharmarajan recommends that radiation oncologists host talks and grand round lectures to medical oncologists and palliative care physicians to highlight new literature on palliative radiation therapy. Additionally, in teaching hospitals, residents and fellows from other medical specialties should have the opportunity to rotate for a week or two in the radiation oncology department.
“As radiation oncologists, we all have the opportunity to be champions of the principles and practice PRT. This means that having upfront conversations about what palliative radiation treatment can and cannot accomplish, and describing a range of outcomes (of both radiation treatment as well as overall prognosis where appropriate) in a manner that is understandable and acceptable to a patient, family, and referring provider, are critical components of shared decision-making,” she said. “These things everyone should strive to do no matter the practice environment.”
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Benefits of a palliative radiation therapy consulting service. Appl Rad Oncol.