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Palliative Radiotherapy We Can Actually

Afford: A New Program Designed to Help

Patients and Caregivers Save Resources

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Christopher Abraham, MD

Assistant Professor

Department of Radiation Oncology

Washington University School of Medicine

Patrick White, MD, HMDC, FACP, FAAHPM

Chief Medical Officer, BJC Home Care

Assistant Professor of Medicine

Washington University School of Medicine

Disclosure: There are no relevant financial

relationships to disclose regarding

this presentation

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Patrick White, MD

Chris Abraham, MD

1) Describe 3 potential benefits of palliative radiation

2) Identify 3 obstacles to the use of palliative radiation in

the hospice setting

3) Describe how a new program can make palliative

radiation available to all hospice patients

Objectives

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My Background

• Internal Medicine-

Washington

University/BJH

• PhD Program, Clinical and

Translational Science,

University of Pittsburgh

• Co-Chief Medical Officer,

University of Pittsburgh’s

Hospice Program

• Chief Medical Officer, BJC

Home Care

My Background

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• MD, Saint Louis

University

• Radiation Oncology

Residency, Barnes-

Jewish Hospital

• Assistant Professor,

Department of

Radiation Oncology

Washington University

in St. Louis

States Worse Than Death Among Hospitalized

Patients With Serious Illnesses

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Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med. 2016 PMID 24479808

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Radiotherapy Basics

• Radiotherapy utilizes high energy radiation to damage DNA

– X-rays, gamma rays, charged particles

– DNA damage is not specific to cancer cells alone

• Radiotherapy may be delivered locally or systemically

• Local radiotherapy may be delivered externally or internally

• Radiation dose is prescribed in Gray and fractions

• Fractionation is utilized to:

– Minimize normal tissue toxicity

– Increase the likelihood DNA damage

Radiotherapy Basics

• Radiotherapy may be given with definitive OR palliative

intent

• Nearly 50% of all radiotherapy is given with palliative

intent

• Radiotherapy prescription dichotomy:

– Local control IS impacted by dose

• Locally advanced lung cancer: 60Gy/30 fractions

– Palliative effect IS NOT impacted by dose

• Bone metastasis: 8Gy/1 fraction

Historical Perspective

• “When the initial objective of

radiation therapy is palliation,

new ground rules must be

applied. Possible serious

complications or even slowly

self-limiting side effects of

treatment are no longer

acceptable. Overall treatment

time must be short. Cost must

be minimized. Convenience of

treatment must be

considered.” - JAMA, 1964

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Palliative Radiotherapy

• Palliative radiotherapy:

– Effective at improving symptoms

• Pain

• Dysphagia / odynophagia

• Bleeding

• Obstruction

– Improves quality of life

– Safe with limited side effects

– Time-efficient

– Cost-effective

– Convenient

Palliative Radiotherapy Indications

• Primary Sites of Disease

– Brain – headaches, neurologic dysfunction

– Head and neck – pain, bleeding, dysphagia, SOB

– Lung – pain, hemoptysis, SVC, post-obstructive PNA

– GU – pain, hematuria, obstruction

– GI – pain, bleeding, tenesmus, obstruction

• Secondary Sites of Disease

– Bone – pain, cord compression

– Skin, subcutaneous tissues

– Spleen – pain, early satiety

– Overlap with primary sites of disease

Palliative Radiotherapy Exclusions

• Patient

– Imminent death

– Inability to provide consent

– Multiple progressive systems

• Treatment

– Side effects > risks

– Unsafe

• Health Care System

– Cost

– Transportation

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Site Specific Treatment

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Bone Metastases

Bone Metastasis

Palliative Radiotherapy Trials for Bone Metastasis: A Systematic Review

Chow, JCO 2007

• Meta-analysis including 16 randomized trials

• >5000 patients in total

• Randomized between single fraction vs. multiple fractions– 8Gy / 1 fraction vs 20Gy/5, 30Gy/10, etc

• Multiple pathologic types included

• Multiple outcomes assessed:– Overall response

– Complete response

– Re-treatment

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Bone Metastasis

• Overall response

– Single fraction: 58%, Multi fraction: 59%

Bone Metastasis

• Complete response

– Single fraction: 23%, Multi fraction: 24%

Bone Metastasis

• Re-treatment

– Single fraction: 20%, Multi fraction: 8%

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Bone Metastasis: Re-treatment

Single versus multiple fractions of repeat radiation for

painful bone metastasis: a randomized controlled, non-

inferiority trial

Chow, Lancet Onc 2014

• RCT of 8Gy / 1fx vs. 20Gy / 5 fx RT for re-treatment

• No difference in overall pain response

• Acute radiation related toxicities higher in multi-fraction

• No difference in cord compression or pathologic fracture

Bone Metastasis: End of Life

Efficacy of radiotherapy for painful bone metastases

during the last 12 weeks of life: results from Dutch

Bone Metastasis Study

Meeuse, CA 2010

• RTC of single vs multi fraction radiotherapy

• Cohort of patients who died within 12 weeks after

randomization

• Results

– Pain response 45% overall

– Median time to relief 2 weeks

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Bone Metastasis Conclusions

• For bone metastasis:

– Radiotherapy is effective at improving pain

– Single fraction is equivalent to multi fraction:

• Overall response

• Complete response

– Re-treatment rates are 2.5 times with single fraction

radiotherapy

• When re-treatment:

– Re-treatment is effective at improving pain

– Single fraction is equivalent to multi fraction

• Palliative radiotherapy is effective at the end of life

Spinal Cord Compression

Spinal Cord Compression

8Gy single dose radiotherapy is effective in metastatic

spinal cord compression: Results of a phase III

randomized multicenter Italian trial

Maranzano, Rad Onc 2009

• RCT of 8Gy / 1 fraction vs 8Gy / 2 fractions for MSCC

• Patients with short life expectancy

• No difference in response

– Pain

– Motor and sphincter function

• No difference in duration of response

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Other sites

Thoracic

Palliative Thoracic Radiotherapy for Lung Cancer: A

Systematic Review

Fairchild, JCO 2007

• Meta-analysis including 13 randomized trials

• >3000 patients

• Randomized patients to short or long course

• Multiple outcomes assessed

– Symptom palliation

– Survival

– Toxicity

– Re-irradiation rate

Thoracic (Hemoptysis)

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Thoracic (Cough)

Thoracic (Chest Pain)

Esophageal Stricture

Single-dose brachytherapy verus metal stent

placement for palliation of dysphagia from

oesophageal cancer: multicenter randomized trial

Homs, Lancet 2004

• Prospective randomized trial

• Randomized between stent and brachytherapy

• >200 patients

• Results:

– Stent more rapid relief

– Brachy more long relief, improved QOL

– Brachy fewer complications

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Large Pelvic Masses

Phase II study of multiple daily fractionations in palliation of advanced pelvic malignancies: preliminary report of RTOG 8502

Spanos, IJROBP 1989

• 152 pts with advanced pelvic malignancies– Gyn, colorectal, GU, misc

• 3.7Gy BID x 2 days, 3-6 weeks off, repeat x2

• Total of 44.4Gy

• After completion of 3 courses:– CR – 15%

– PR – 32%

– Stable - 35%

Conclusions

• Palliative radiotherapy is:

– Effective

– Safe

– Time efficient

• Radiotherapy is useful for:

– Primary and secondary disease

– Multiple anatomic sites

• Single fraction radiation is often reasonable and

appropriate means for palliation

• Perception

– Hospice Provider’s Perception

– Radiation Oncologists Perception

• Barriers

– Educational Barriers

– Economic Barriers

– Research Barriers

• Outcome

– Less than 3% of hospice patients receive radiation therapy

Barriers to Radiation Therapy in Hospice Care

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Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative care of the patient with

cancer. J Clin Onc. 2014; 32(26):2913-9.

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Question % Yes

1) Is radiation therapy (RT) important in palliative care? 87%

2) Do you feel sufficiently trained for when to use RT? 52%

3) Is RT available to your patients? 74%

4) Do you have access to a radiation oncologist to discuss your patients?

75%

5) Would you be willing to attend palliative RT lectures? 94%

Barriers to Radiation Therapy in Hospice Care:

Survey of Hospice Providers (Easy Questions)

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Lutz S, Spence C, Chowe E, Janjan N, Connor S. Survey on use of palliative radiotherapy in

hospice care. J Clin Oncol. 2004; 22(17):3581-3586.

Question % Yes

1) Do you feel radiation oncologists are sufficiently trained in palliative care to render opinions regarding treatment of hospice cancer patients?

56%

2) Are radiation oncologists resistant to prescribing single-fraction treatments?

76%

3) Would you be willing to recruit hospice patients into trials measuring the worth of palliative radiotherapy in certain circumstances?

59%

Barriers to Radiation Therapy in Hospice Care:

Survey of Hospice Providers (Hard Questions)

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• Lack of formal palliative care training for radiation

oncology residents

• Lack of radiotherapy training for palliative care

professionals

• Minimal protected time at national meetings for palliative

oncology topics

• Lack of training for hospice clinicians in identifying

situations where radiation therapy may improve QOL

Educational Barriers

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Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative care of

the patient with cancer. J Clin Onc. 2014; 32(26):2913-9.

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• Economic incentives to prescribe protracted courses of

radiation therapy

• Radiotherapy costs several times the average hospice

per diem

• Transportation costs are often borne by hospice

organizations and may even be more expensive than the

radiotherapy itself

• Caregivers may not be able to take the time off work to

complete protracted course of radiation therapy

Economic Barriers

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Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative care of the

patient with cancer. J Clin Onc. 2014; 32(26):2913-9.

Economic Impact of Single-fraction Versus

Multi-fraction Radiotherapy

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International Variation in Practice Patterns Comparing

Single-Fraction to Multi-fraction Radiotherapy

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• Paucity of experienced research teams in hospice and

palliative care programs

• Missing data points because of declining health or death

of accrued patients

• Lack of federal funds dedicated to end-of-life studies

• Paucity of clinical trials comparing different radiation

regimens for many conditions (outside of painful bone

metastases)

Research Barriers

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Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative

care of the patient with cancer. J Clin Onc. 2014; 32(26):2913-9.

• More focused collaborations between radiation

oncologists and hospice/palliative care physicians

• Emphasis on hypofractionated courses for patients with

poor prognoses

• Formalized training for both radiation oncology residents

and palliative care fellows on the nuances of palliative

radiotherapy

• Formation of more radiotherapy overuse guidelines and

quality measures and increased accountability

Improving Access to Radiotherapy

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Hospice / Palliative Logistics

for New Palliative

Radiotherapy Clinic at CHNE

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Who- Any hospice patient with painful bone metastases or

spinal cord compression regardless of hospice provider

What-Palliative radiation clinic specializing in single fraction

radiotherapy

Where-Christian Hospital Northeast in Saint Louis

When-Now!

Why-Need for inexpensive, single fraction radiation therapy

to help improve quality of life while reducing the burdens on

patients and caregivers

New Palliative Radiation Oncology Clinic

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• Reduced Professional Fee-Washington University

Radiation Oncology has agreed to bill only a 99203

($290.52) which is a level 3 visit with low complexity

• Christian Hospital will allow a single fraction without a CT

simulation or additional imaging to keep costs ($328.13)

minimal.

• Total costs for the technical fee and professional fee and

imaging will be $618.65 (adjusted for Medicare Fee

Schedule) and the entire process will typically be

conducted in one visit!

• This could result in reduced ambulance costs, lower

caregiver burden, decreased transportation discomfort,

longer hospice LOS, etc.

What Makes This Radiotherapy Practical

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• Is the patient able to lie flat?

– (okay if not but need to know)

• Is the patient able to follow instructions, can the safely

be placed on a treatment table?

• Is the patient decisional to sign consent for treatment?

– if not POA must be present for consult and treatment to give

consent.

Information Needed From the Referring Hospice

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Logistics

Hospice determines radiotherapy need

Case discussed with Radiation Oncology

Formal referral rendered

Continued assessment of need

Radiation Oncology assessment

Simulation

Quality Assurance

Delivery of single fraction radiotherapy

Transportation

Pre-medication

• Conway JL, Yurkowski E, Glazier J, et al. Comparison of Patient-reported Outcomes with a Single

Versus Multiple Fraction Palliative Radiotherapy for Bone Metastasis in a Population-based Cohort. Radiother Oncol. 2016; 119(2):202-207.

• Chow E, van der Linden YM, Roos D, et al. Lancet Oncol. Single Versus Multiple Fractions of Repeat Radiation for Painful Bone Metastases: a Randomized, Controlled, Non-inferiority Trial.

2014 Feb;15(2):164-71.

• Collinson L, Kvizhinadze G, Nair N, McLeod M, Blakely T. Economic Evaluation of Single-fraction

Versus Multiple-fraction Palliative Radiotherapy for Painful Bone Metastases in Breast, Lung and

Prostate Cancer. J Med Imaging Radiat Oncol. 2016; 60(5):650-660.

• Chow E, Hahn CA, Lutz ST, Global Reluctance to Practice Evidence-based Medicine Continues in

the Treatment of Uncomplicated Painful Bone Metastases Despite Level 1 Evidence and Practice Guidelines. Int J Radiat Oncol Bio Phys. 2012;83(1):e117-120.

• Saito T, Toya R, Semba A, et al. Influence of the Treatment Schedule on the Physicians' Decisions

to Refer Bone Metastases Patients for Palliative Radiotherapy: a Questionnaire Survey of

Physicians in Various Specialties. Nagoya J Med Sci. 2016; 78(3):275-84.

• Fairchild A, Barnes E, Ghosh S, et al. International Patterns of Practice in Palliative Radiotherapy

for Painful Bone Metastases: Evidence-based Practices? Int. J. Radiation Oncology Biol. Phys.

2009;75(5):1501-1510.

• Thavarajah N, Zhang L, Wong K, Bedard G. Patterns of Practice in the Prescription of Palliative

Radiotherapy for the Treatment of Bone Metastases at the Rapid Response Radiotherapy Program Between 2005 and 2012. Curr Oncol. 2013 Oct;20(5):e396-405.

References

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• McDonald R, Ding K, Brundage M, et al. Effect of Radiotherapy on Painful Bone Metastases: A

Secondary Analysis of the NCIC Clinical Trials Group Symptom Control Trial SC.23. JAMA Oncol. 2017. Epub ahead of print.

• Howell DD, James JL, Hartsell WF, Suntharalingam M. Single-fraction Radiotherapy Versus Multi-fraction Radiotherapy for Palliation of Painful Vertebral Bone Metastases-equivalent Efficacy, Less

Toxicity, More Convenient: a Subset Analysis of Radiation Therapy Oncology Group trial 97-14.

Cancer. 2013; 119(4):888-96.

• Moghanaki D, Cheuk AV, Fosmire H, Anscher MS. Availability of Single-fraction Palliative

Radiotherapy for Cancer Patients Receiving End-of-life Care Within the Veterans Healthcare Administration. J Palliat Med. 2014;17(11):1221-5.

• Lutz ST, Jones J, Chow E. Role of Radiation Therapy in Palliative Care of the Patient with Cancer. J Clin Oncol. 2014; 32(26):2913

• Lutz S, Spence C, Chow E, Janjan N, Connor S. Survey on Use of Palliative Radiotherapy in

Hospice Care. J Clin Oncol. 2004; 22(17):3581-6.

• McCloskey SA, Tao ML, Rose CM, Fink A, Amadeo AM. National Survey of Perspectives of

Palliative Radiation Therapy: Role, Barriers, and Needs. Cancer J. 2007; 13(2):130-7.

References (continued)

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