The Profession
Use of Radiation Therapy Within the Last Year of Life Among Cancer Patients

https://doi.org/10.1016/j.ijrobp.2018.01.056Get rights and content

Purpose

We examined radiation therapy (RT) use within the last year of life (LYOL). As palliative RT (PRT) has been well studied in patients with ≥6-week life expectancies, we hypothesized that PRT use would be constant over the LYOL, except for the last 30 days, when use would decline given lack of prospective data supporting it.

Materials and Methods

At a single institution, 870 cancer patients died between October 2, 2014, and September 30, 2015, and had ≥3 evaluation and management visits within the LYOL. Claims and RT data were extracted and linked. Over the LYOL, we evaluated RT use by intent (curative vs palliative) and indications.

Results

Within the LYOL, one-third of patients underwent RT in the last 365 days of life to 444 sites, which decreased to 24.3% and 8.5% in the last 180 and 30 days of life, respectively. Patients who received any RT in the last 365 days of life were younger at death and had a higher proportion of lung, sarcoma, and transplant disease groups. One-quarter of sites were irradiated with curative intent, which remained constant over the LYOL. In contrast, PRT was used at a supralinear rate, in which treatment of bone metastases and use of single-fraction PRT increased closer to death.

Conclusions

PRT appears to be disproportionately used closer to death, with an increasing proportion of irradiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer toward the end of life. As patients with very poor prognoses (eg, within 30 days of death) are generally not included in RT clinical trials, further studies are warranted to assess whether PRT for bone metastases at the end of life is efficacious.

Introduction

The indications for and efficacy of palliative radiation therapy (RT) have been well established among advanced cancer patients through prospective, randomized clinical trials. However, in most studies, including those of uncomplicated bone metastases, patient eligibility required life expectancies of ≥6 weeks 1, 2, 3, 4, 5, 6. Most data on palliative RT have therefore been obtained in patients who are not immediately near death. Moreover, as cancer progression is often associated with increased symptoms and the rate of progression may increase closer to death, it is unclear how RT is used in real clinical practice. Single-institution (7) or population-based studies 8, 9, 10, 11 have described palliative RT use, typically within the last 14 or 30 days of life, but few data exist on how this compares with other time points, such as the temporal use of RT among cancer patients within the last year of life, and none have included treatment intent by RT course and as determined by the treating radiation oncologist.

We hypothesized that as palliative RT has been well studied in patients with life expectancies of ≥6 weeks, palliative RT use would be constant over the remaining year of life, except for the last 30 days, when use would decline. We conducted this single-institution retrospective study to understand the temporal use of RT within the last year of life. These results would allow us to: (1) better anticipate an advanced cancer patient's needs and indications for RT at different stages of the disease course; and (2) identify any gaps between the timing of palliative RT delivered in clinical trials and “real-world” clinical practice.

Section snippets

Description of cohort

Among patients seen at University of Washington Medical Center (UWMC), Seattle Cancer Care Alliance (SCCA), and Northwest Hospital (NWH), 1187 died between October 2, 2014, and September 30, 2015. Of these, 880 had ≥3 evaluation and management visits within the last year of life, and 870 had a diagnosis of cancer. These 870 patients comprised the analysis cohort. Only patients with ≥3 evaluation and management visits were included based on the assumption that these patients were more likely to

Patient characteristics

Among 870 cancer patients, 290 (33.3%), 211 (24.3%), and 74 (8.5%) received RT within the last 365 days, 180 days, and 30 days of life, respectively. Patients treated with RT within the last 365 days of life (RT365) were significantly younger at death (Table 1). RT was variably used across disease sites. Patients with gastrointestinal, gynecologic, or hematologic malignancies were less likely to receive RT in the last 365 days of life. In contrast, patients undergoing transplant or with head

Discussion

Within our single-institution cohort of cancer patients, approximately one-third of patients received RT in the last 365 days of life. RT was variably used across cancer types and over the last 365 days of life. While prior studies have evaluated palliative RT use near the end of life, to our knowledge, this is one of the first studies to evaluate curative RT delivered across the last year of life. Notably, 31% of patients who died within 1 year of RT treatment were treated with curative

Conclusions

Palliative RT appears to be disproportionately used closer to death, with an increasing proportion of irradiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer near the end of life. However, the impact of palliative RT in the last 30 days of life is uncertain. Future studies on efficacy are needed.

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    Conflict of interest: none.

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