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Family physicians' perspectives regarding palliative radiotherapy
Radiotherapy and Oncology 78 (2006) 101–106 www.thegreenjournal.com
Palliative radiotherapy
Family physicians’ perspectives regarding palliative radiotherapy Rajiv S. Samanta,b,*, Edward Fitzgibbonb, Joanne Menga,b, Ian D. Grahamb,c a
Ottawa Regional Cancer Centre, Ottawa, Ont., Canada, bUniversity of Ottawa, Ottawa, Ont., Canada, cOttawa Health Research Institute, Ottawa, Ont., Canada
Abstract Purpose: To assess family physicians’ views on common indications for palliative radiotherapy and to determine whether this influences patient referral. Methods and materials: A 30-item questionnaire evaluating radiotherapy knowledge and training developed at the Ottawa Regional Cancer Centre (ORCC) was mailed to a random sample of 400 family physicians in eastern Ontario, Canada. The completed surveys were collected and analyzed, and form the basis of this study. Results: A total of 172 completed surveys were received for a net response rate of 50% among practicing family physicians. Almost all of the physicians (97%) had recently seen cancer patients in their offices, with 85% regularly caring for patient with advanced cancer. Fifty-four percent had referred patients in the past for radiotherapy and 53% had contacted a radiation oncologist for advice. Physicians who were more knowledgeable about the common indications for palliative radiotherapy were significantly more likely to refer patients for radiotherapy (P!0.01). Inability to contact a radiation oncologist was correlated with not having referred patients for radiotherapy (P!0.01). Only 10% of the physicians had received radiotherapy education during their formal medical training. Conclusions: Many of the family physicians surveyed were unaware of the effectiveness of radiotherapy in a variety of common palliative situations, and radiotherapy referral was correlated with knowledge about the indications for palliative radiotherapy. This was not surprising given the limited education they received in this area and the limited contact they have had with radiation oncologists. Strategies need to be developed to improve continuing medical education opportunities for family physicians and to facilitate more interaction between these physicians and radiation oncologists. q 2005 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 78 (2006) 101–106. Keywords: Radiotherapy; Palliation; Education; Family physicians
Radiotherapy is an essential, established treatment modality in the management of many malignancies, playing a major role in both the curative and adjuvant setting as well as for palliation [1–5]. Expert opinion suggests that 50–60% of all cancer patients could benefit from radiotherapy [4,6–8]. However, in Ontario (Canada), radiotherapy is used in less than 35% of cancer patients [7] and this under-use of radiotherapy is even more notable for treatment with a palliative intent than for potentially curative treatment [9]. In fact, within Ontario, it appears as though palliative radiotherapy utilization is decreasing in comparison to radical or adjuvant treatment [10]. This is surprising considering that palliative radiotherapy is less resource intensive than curative or adjunctive radiotherapy [11] and suggests that factors other than insufficient treatment resources may be contributing to the under-use of palliative radiotherapy [7,9,12]. Concerned that a lack of knowledge about the value of palliative radiotherapy may have been playing a major role
in its under-use, we at the Ottawa Regional Cancer Centre (ORCC) decided to investigate this further. The ORCC serves as the sole radiotherapy referral center for eastern Ontario with a catchment population of approximately 1.3 million people. Within this region, family physicians provide much of the day-to-day care for cancer patients including palliative care. Therefore, we decided to evaluate their knowledge and perspectives about palliative radiotherapy to determine if this was influencing their decision to refer cancer patients for such treatment.
Methods and materials A panel including a survey expert, two radiation oncologists and a palliative care physician developed seven pages, 30-item questionnaire, to evaluate knowledge about the indications for palliative radiotherapy and the factors influencing patient referral among family physicians in our
0167-8140/$ - see front matter q 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.radonc.2005.11.008
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Family doctors and palliative radiotherapy
community. It included the following sections: (1) respondent characteristics; (2) awareness of and perceived accessibility to oncology services at the Regional Cancer Centre; (3) factors influencing radiotherapy referral for palliation; (4) perception of the effectiveness of palliative radiotherapy; and (5) willingness to attend continuing medical education on radiation oncology. It was intended for self-completion and required 10–15 min to complete. The questionnaire was pilot tested on a group family physicians attending a primary care oncology update meeting in order to establish face validity, ease of completion, content, value and relevance, and completion time of 10–15 min. The survey sample frame of family physicians in the Eastern Ontario region was compiled using a combination of the Southam Canadian Medical Directory and the ORCC list of family physicians who had previously referred patients to the ORCC. The final survey sample frame consisted of 997 family physicians. In early 2002 the survey was mailed to a random sample of 400 of these family physicians. Knowledge about palliative radiotherapy was assessed by the number of correct responses to seven common indications for palliative radiotherapy as shown in Table 1. The questions were primarily used to determine knowledge about common indications for palliative radiotherapy rather than rigorously evaluating radiotherapy knowledge. The effectiveness of radiotherapy for the various situations was based on the opinions and experience of the authors as well as established published data [13]. Either ‘somewhat effective’ or ‘very effective’ were considered correct answers for scenarios 3 through 7 while ‘very effective’ was considered the only correct answer for scenarios 1 and 2. The expert panel decided that 6–7 out of 7 correct responses represented good knowledge about palliative radiotherapy, 4–5 out of 7 correct responses represented fair knowledge and 0–3 out of 7 correct responses represented poor knowledge. The completed surveys were collected and the responses were collated, and analyzed. A profile of family physicians that refer patients for palliative radiotherapy was constructed using multi-variate logistic regression modeling techniques.
Table 1 Questions evaluating palliative radiotherapy knowledge How effective do you consider radiotherapy for the following cancer related symptoms? (1) Painful bony metastases (2) Spinal cord compression (3) Hemoptysis (4) Hematuria (5) Painful local disease (6) Brain metastases (7) Airway obstruction Available choice of responses for each question Not effective Somewhat effective Very effective Donot know
Table 2 Demographics of responding family physicians Demographic variable Gender Female Male Year of graduation Mean Range Years practicing family medicine Mean Range CCFPa Yes No Practice setting Urban Rural Hospital admitting privileges Yes No a
Responders % (nZ172) 44 56 1980 1948–1998
18 years 0–40 years 64 36 64 36 52 48
CCFP, Certificant of Canadian College of Family.
Results Of the 400 surveys that were sent out, 55 were returned and deemed ineligible because the physicians did not practice family medicine, did not have cancer patients in their practice or had moved with no forwarding address. The survey return rate was 57% (227/400) and this represents approximately 23% of all family physicians in the region. A total of 172 completed surveys were received for an overall response rate for eligible respondents was 50% (172/345). General demographic information regarding the respondents is shown in Table 2. Almost all (97%) family physicians had seen cancer patients within the last month, with 85% looking after patients with advanced cancer. Eighty percent were involved in providing palliative care for their patients. Approximately 56% had referred patients for radiotherapy in the past and 53% had contacted a radiation oncology for advice in the past. Only 10% of all family physicians received formal radiotherapy education during their medical training and an additional 6% received some radiotherapy education after completing their medical training. The amount of training received was quite variable, ranging from one lecture to clinical rotations of over 1 year. Fig. 1 shows the knowledge about the indications for palliative radiotherapy among the responding family physicians. As indicated by Fig. 2, level of knowledge about the common indications for palliative radiotherapy was correlated with radiotherapy referral (P!0.01). Specifically, physicians most knowledgeable about the indications for palliative radiotherapy were also the most likely to have referred patients for radiotherapy in the past. This trend was noted even if ‘somewhat effective’ or ‘very effective’ were considered appropriate answers to the all the indications for palliative radiotherapy. Fig. 3 shows the responses among the physicians for each of the palliative situations for which radiotherapy could be
R.S. Samant et al. / Radiotherapy and Oncology 78 (2006) 101–106
103
Fig. 1. Knowledge of the indications for palliative radiotherapy physicians*. *Based on the number of correct responses ( ).
Fig. 3. Physicians’ perceptions on radiotherapy effectiveness for palliative conditions.
used. Although more than 50% correctly thought that radiotherapy was ‘very effective’ for painful bone and soft tissue metastases, less than 40% felt the same about the value of radiotherapy for other palliative situations such as brain metastases and spinal cord compression. In fact, only 14% thought that radiotherapy was ‘very effective’ for hemoptysis. Almost two-thirds of respondents were either unsure of the value of radiotherapy for hemoptysis and hematuria or thought it was ineffective, and almost half were uncertain about the value of radiotherapy for spinal cord compression or thought it was ineffective. When asked about factors affecting patient referral for palliative radiotherapy, 54% stated that uncertainty about benefits influence their referral ‘somewhat’ or ‘a lot’. Approximately 42% stated that life expectancy influenced their decision to refer patients with over one third of these physicians thinking that life expectancy should be 4 months or greater prior to referring patients for palliative radiotherapy. As shown in Table 3, other factors found to be strongly correlated (P!0.05) with patient referral for radiotherapy included a greater volume of cancer patients seen per month, increased frequency of providing palliative care, rural practice location and having contacted a radiation oncologist for advice in the past. Interestingly,
training in palliative care did not seem to influence referral for radiotherapy. Eighty-six percent of the physicians stated they would benefit from more education about radiation oncology and 87% would be willing to attend continuing medical education (CME) events on radiotherapy and its use in oncology. The preferred formats for learning were small group tutorials and workshops along with written materials.
Fig. 2. Relationship between knowledge of palliative radiotherapy indications and referral for radiotherapy.
Discussion The vast majority of family physicians surveyed were actively involved in the care of cancer patients. This has been documented in other studies, which show that family physicians provide much of the cancer care including palliative care to cancer patients in Canada [14,15] and elsewhere in the world [5,16]. Also, our respondents had little training in radiation oncology, which is consistent with the limited published literature in this area [17–20]. This situation is quite interesting when one considers the fact that family physicians continue to play a major and possibly increasing role in the management of cancer patients [14], and therefore, should be expected to have reasonable basic knowledge of oncology, including radiotherapy. The results of this study show that knowledge about the common indications for palliative radiotherapy among family physicians is less than ideal as many physicians were not aware of all of these indications. This should not be entirely surprising considering that less than 20% of the respondents had any formal education in the area of radiation oncology, either during their basic medical training or since completion of their training. Interestingly, in a study from Alberta (Canada), Barnes et al. [21] found very similar results regarding family physicians’ knowledge about the value for palliative radiotherapy. A recent American study found that physicians working in the hospice setting also recognize their educational deficiencies with regards to palliative radiotherapy knowledge [22]. The published literature indicates that undergraduate medical school training in oncology has been inadequate in the past
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Table 3 Comparison of family physicians referring and not referring for radiotherapy Variable Years in practice Mean Range Volume of cancer patients/month !5 6–10 O10 Frequency of providing palliative care Never Rarely Sometimes Often Training in palliative care Yes No Knowledge levela PoorZ0–3 FairZ4–5 GoodZ6–7 Accessibility of radiation oncologist Never tried Easy Difficult Practice setting Urban Rural a
Refer (nZ96) %
Not refer (nZ76) %
Test of association chi-square (c2) P!0. 05 unpaired t-test P!0.05
19.2 years 0–40
17.1 years 3–36
t-test(P)Z0.1205
39.6 31.2 29.2
58.0 33.0 9.0
(c2)PZ0.0169
1.0 3.2 29.5 66.3
3.9 30.3 35.5 30.3
(c2)P!0.0001
41.7 58.3
37.8 62.2
(c2)PZ0.6134
5.3 47.4 47.3
25.7 51.3 23.0
(c2)PZ0.0004
8.0 60.5 31.5
40.0 35.0 25.0
(c2)PZ0.0001
55.2 44.8
75.0 25.0
(c2)PZ0.0073
FP level of knowledge based on correctly answering indications for palliative radiotherapy; rangeZ0–7 correct answers.
[14,17,20,23] and although attempts at improving oncology education are being carried out, it remains uncertain if they are achieving their goals [24–26]. The fact that only half of respondents had ever contacted a radiation oncologist indicates that there is limited interaction occurring between cancer specialists and primary care physicians, and we believe that this needs to change. Other studies have also identified the need for better communication between oncologists and family physicians [16,21]. Although referrals for curative and adjuvant radiotherapy often come from specialists (such as medical oncologists, surgeons and hematologists), the majority of patients with advanced incurable cancer are followed by their family physician and, given the evidence for the benefit of palliative radiotherapy, we would expect more referrals from them for such treatment. This pattern of under referral may be partly explained by the finding that over half the family physicians surveyed stated that uncertainty about the benefits of palliative radiotherapy influenced their decision to some degree. As has been documented in another Canadian study [27], other factors, such as waiting times for consultation and treatment, were found to influence patient referral for radiotherapy among our respondents and have been reported separately [28]. The findings that physicians seeing more cancer patients and physicians involved in palliative care are more likely to
refer patients for radiotherapy seems obvious. We also found that rural physicians are more likely to provide more extensive cancer care for their patients. However, this is one of the first studies to demonstrate a direct relationship between a family physicians’ level of knowledge about the indications for palliative radiotherapy and referral of patients for radiotherapy. Therefore, it is important to ensure that better knowledge of radiation oncology is provided. The vast majority of the family physicians who responded to this survey indicated a need for and a desire to participate in ongoing education in this area. Residency training programs for family physicians need to emphasize the important role that they play in cancer care and must provide trainees with the basic knowledge and tools required to do this. The published literature shows that family physicians do not have enough training in oncology [23,25,29–32] and this is especially true for radiation oncology [20,21,24,31,33]. This deficiency is not just in the province of Ontario or within Canada but throughout the world [20,24]. The reasons for the lack of training are multifactorial [22,25,29,30,32]. However, the best ways in which to improve education about the practical aspects of oncology including radiotherapy are still debated [20,21,24,26,33]. Radiotherapy is such an important part of cancer treatment that family physicians need to have a basic understanding of this treatment
R.S. Samant et al. / Radiotherapy and Oncology 78 (2006) 101–106
modality. Therefore, initiatives to improve radiotherapy education are necessary. This may increase the number of appropriate referrals for radiotherapy, especially in the palliative setting. We are now in the process of developing ways to improve oncology knowledge in our region. The published literature on medical education [33–35] indicates that the most useful types of educational tools to help influence practice include use of local opinion leaders, development of relevant treatment guidelines, outreach visits and interactive education. Therefore, our plans include going into communities via a radiotherapy ‘road show’ type of format in order to give family physicians and other health care workers a clearer idea of exactly what types of services are available for their cancer patients and the evidence supporting their use. We also want to meet with local physician leaders and develop practical treatment guidelines for family physicians regarding the role of radiotherapy in the management of cancer patients. Tours of the Cancer Centre facility and possibly rotations through the Radiotherapy Department are also being considered. Our study has some limitations that could reduce the generalizability of our findings. This includes the response rate of 50% (which represents just under one quarter of family physicians in our region) that could lead to response bias since the responses received may not fairly reflect all family physicians. However, the response rate still compares favorably with other physician surveys [36]. The survey was self- reported and there is no clear documentation of radiotherapy referral. For example, if a physician claims that he or she had referred patient in the past for radiotherapy, this could not be independently verified. Finally, the evaluation of radiotherapy knowledge was not exhaustive and may not accurately reflect basic radiotherapy knowledge, and also did not use a validated instrument to measure palliative radiotherapy knowledge. However, the goal of the questions was to determine if the common indications for palliative radiotherapy were known to the family physicians and it was not our intent to perform a complete evaluation of radiotherapy knowledge.
Summary At present, many family physicians have less than optimal knowledge about the indications for palliative radiotherapy. Family physicians with insufficient knowledge of the indications for and effectiveness of palliative radiotherapy appear less likely to refer cancer patients for radiotherapy. Family physicians need to know more about radiotherapy so they can provide appropriate care for their cancer patients and know when to refer them for such treatment. To that end, radiation oncologists need to participate more in educating non-oncology physicians. They need to be more accessible to primary care physicians and have a greater profile within the communities they serve. Radiation oncologists need to think of themselves as ambassadors for their cancer centers and specifically advocates for the appropriate use of radiotherapy treatment. Our study indicates that family physicians are aware of their
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need to improve their radiotherapy knowledge and are keen to learn more.
* Corresponding author. Address: Ottawa Regional Cancer Centre, 503 Smyth Road, Ottawa, Ont., Canada K1H 1C4. E-mail address: [email protected] Received 17 June 2004; received in revised form 12 April 2005; accepted 10 November 2005; available online 5 December 2005
References [1] Ashby M. The role of radiotherapy in palliative care. J Pain Symptom Manage 1991;6:380–8. [2] Coia LR, Owen JB, Maher EJ, et al. Factors affecting treatment patterns of radiation oncology in the United State in the palliative treatment of cancer. Clin Oncol 1992;4:6–10. [3] Fine P. Palliative radiation therapy in end-of-life care. Am J Hosp Palliat Care 2002;19:166–70. [4] Perez C, Brady L, editors. Principles and practice of radiation oncology. 3rd ed. Am Fam Physician 1999:59(5):1183. [5] Tisdale BA. When to consider radiation therapy for your patient. Am Fam Physician 1999;59:1177–84. [6] Levitt SH, Leer JW. The role of radiotherapy in Sweden—a landmark study by the Swedish council on technology assessment in health care (editorial). Acta Oncol 1996;35: 965–6. [7] MacKillop WJ, Groome PA, Zhang-Salomons J, et al. Does a centralized radiotherapy system provide adequate access to care? Clin Oncol 1997;15:1261–71. [8] American College of Radiology, 1991. Radiation oncology in integrated cancer management: report of the inter-society council for radiation oncology. Reston, VA: American College of Radiology; Current Oncology 1991;9(1). [9] Mackillop WJ, Zhou S, Groome P, et al. Changes in the use of radiotherapy in Ontario 1984–1995. Int J of Radiat Oncol Biol Phys 1999;44:355–62. [10] Tyldesley S, Zhang-Salomons J, Groome PA, et al. Association between age and the utilization of radiotherapy in Ontario. Int J Radiat Oncol Biol Phys 2000;47:469–80. [11] Samant RS, Roberts GH, Dunscombe PB. Case-costing of palliative radiotherapy: a canadian single-institution perspective. Curr Oncol 2002;9:20–6. [12] Huang J, Zhou S, Groome P, et al. Factors affecting the use of palliative radiotherapy in Ontario. J Clin Oncol 2001;19:137–44. [13] Kagan AR, Powers WE, Ratanatharathorn V, Janjan N. In: Perez CA, Brady L, (eds.) Principles and practice of radiation oncology, 3rd ed. Philadelphia, PA: Lippincott–Raven Publishers; 1998. p. 2187–257. [14] Dworkind M, Shvartzman P, Adler PSJ, et al. Urban family physicians and the care of cancer patients. Can Fam Physician 1994;40:47–50. [15] McWhinney IR, Hoddinott SN, Bass MJ, et al. Role of the family physician in the care of cancer patients. Can Fam Physician 1990;36:2183–6. [16] Wakefield MA, Beilby J, Ashby MA. General practitioners and palliative care. Palliat Med 1993;7:117–26. [17] Cellerino R, Graziano F, Piga A, et al. The teaching of clinical oncology in Italian medical schools: a survey among teachers and students. Ann Oncol 1993;4:717–21. [18] Mortimer JE, Bartlett NL. Assessment of knowledge about cancer pain management by physicians in training. J Pain Symptom Manage 1997;14:21–8. [19] Skolnick AA. New study suggests radiation often underused for palliation. J Am Med Assoc 1998;279:343–4.
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[20] Smith WT, Tattersal MH, Irwig LM, et al. Undergraduate education about cancer. Eur J Cancer 1991;27:1448–53. [21] Barnes EA, Hanson J, Neumann CM, et al. Communication between primary care physicians and radiation oncologists regarding patients with cancer treated with palliative radiotherapy. J Clin Oncol 2000;18:2902–7. [22] Lutz S, Spence C, Chow E, et al. Survey on use of palliative radiotherapy in hospice care. J Clin Oncol 2004;22:3581–6. [23] Ramakrishnan S, Bolger JJ, Dunn KS, et al. Undergraduate medical teaching in departments of oncology in the United Kingdom: a questionnaire survey. J Cancer Educ 1993;8:25–30. [24] Barton MB, Simons RG. A survey of cancer curricula in Australian and New Zealand medical schools in 1997. Oncology Education Committee of the Australian Cancer Society. Med J Aust 1999;170:199–200. [25] Piga A, Graziano F, Zahra G, et al. Attitudes of non-oncology physicians on dealing with cancer patients. A survey based on clinical scenarios in Ancona province, central Italy. Tumori 1996;82:423–9. [26] Zapka JG, Luckmann R, Sulsky SI, et al. Cancer control knowledge, attitudes, and perceived skills among medical students. J Cancer Educ 2000;15:73–8. [27] Samant R, Fitzgibbon E, Meng J, Graham I. Identifying barriers to palliative radiotherapy referral. Radiother Oncol 2003;69: S25 [abstract].
[28] Brincker H. Undergraduate oncology education in Scandinavia. J Cancer Educ 1988;3:97–101. [29] Ravaud A, Hoerni B, Becouarn Y, et al. A survey in general practice about undergraduate cancer education: results from Gironde (France). J Cancer Educ 1991;6:153–7. [30] Samant R. Palliative care educational needs of family physicians. J Palliat Care 2001;17:227–80. [31] Tattersall MH, Langlands AO, Smith W, et al. Undergraduate education about cancer. A survey of clinical oncologists and clinicians responsible for cancer teaching in Australian medical schools. Eur J Cancer 1993;29A:1639–42. [32] Samant R. Palliative care educational needs of family physicians. J Palliat Care 2001;17:277–80. [33] Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care 2001;39:112–45. [34] Helwig A, Bower D, Wolff M, et al. Residents find clinical practice guidelines valuable as educational and clinical tools. Fam Med 1998;30:431–5. [35] Tracey J, Rodwell P, Clearwater G. Development and evaluation of the rural trauma and emergency care roadshow. N Z Med J 1999;112:144–7. [36] Guadagnoli E, Cunningham S. The effects of nonresponse and late response on a survey of physician attitudes. Eval Health Prof 1989;12:318–28.
Palliative radiotherapy
Family physicians’ perspectives regarding palliative radiotherapy Rajiv S. Samanta,b,*, Edward Fitzgibbonb, Joanne Menga,b, Ian D. Grahamb,c a
Ottawa Regional Cancer Centre, Ottawa, Ont., Canada, bUniversity of Ottawa, Ottawa, Ont., Canada, cOttawa Health Research Institute, Ottawa, Ont., Canada
Abstract Purpose: To assess family physicians’ views on common indications for palliative radiotherapy and to determine whether this influences patient referral. Methods and materials: A 30-item questionnaire evaluating radiotherapy knowledge and training developed at the Ottawa Regional Cancer Centre (ORCC) was mailed to a random sample of 400 family physicians in eastern Ontario, Canada. The completed surveys were collected and analyzed, and form the basis of this study. Results: A total of 172 completed surveys were received for a net response rate of 50% among practicing family physicians. Almost all of the physicians (97%) had recently seen cancer patients in their offices, with 85% regularly caring for patient with advanced cancer. Fifty-four percent had referred patients in the past for radiotherapy and 53% had contacted a radiation oncologist for advice. Physicians who were more knowledgeable about the common indications for palliative radiotherapy were significantly more likely to refer patients for radiotherapy (P!0.01). Inability to contact a radiation oncologist was correlated with not having referred patients for radiotherapy (P!0.01). Only 10% of the physicians had received radiotherapy education during their formal medical training. Conclusions: Many of the family physicians surveyed were unaware of the effectiveness of radiotherapy in a variety of common palliative situations, and radiotherapy referral was correlated with knowledge about the indications for palliative radiotherapy. This was not surprising given the limited education they received in this area and the limited contact they have had with radiation oncologists. Strategies need to be developed to improve continuing medical education opportunities for family physicians and to facilitate more interaction between these physicians and radiation oncologists. q 2005 Elsevier Ireland Ltd. All rights reserved. Radiotherapy and Oncology 78 (2006) 101–106. Keywords: Radiotherapy; Palliation; Education; Family physicians
Radiotherapy is an essential, established treatment modality in the management of many malignancies, playing a major role in both the curative and adjuvant setting as well as for palliation [1–5]. Expert opinion suggests that 50–60% of all cancer patients could benefit from radiotherapy [4,6–8]. However, in Ontario (Canada), radiotherapy is used in less than 35% of cancer patients [7] and this under-use of radiotherapy is even more notable for treatment with a palliative intent than for potentially curative treatment [9]. In fact, within Ontario, it appears as though palliative radiotherapy utilization is decreasing in comparison to radical or adjuvant treatment [10]. This is surprising considering that palliative radiotherapy is less resource intensive than curative or adjunctive radiotherapy [11] and suggests that factors other than insufficient treatment resources may be contributing to the under-use of palliative radiotherapy [7,9,12]. Concerned that a lack of knowledge about the value of palliative radiotherapy may have been playing a major role
in its under-use, we at the Ottawa Regional Cancer Centre (ORCC) decided to investigate this further. The ORCC serves as the sole radiotherapy referral center for eastern Ontario with a catchment population of approximately 1.3 million people. Within this region, family physicians provide much of the day-to-day care for cancer patients including palliative care. Therefore, we decided to evaluate their knowledge and perspectives about palliative radiotherapy to determine if this was influencing their decision to refer cancer patients for such treatment.
Methods and materials A panel including a survey expert, two radiation oncologists and a palliative care physician developed seven pages, 30-item questionnaire, to evaluate knowledge about the indications for palliative radiotherapy and the factors influencing patient referral among family physicians in our
0167-8140/$ - see front matter q 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.radonc.2005.11.008
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Family doctors and palliative radiotherapy
community. It included the following sections: (1) respondent characteristics; (2) awareness of and perceived accessibility to oncology services at the Regional Cancer Centre; (3) factors influencing radiotherapy referral for palliation; (4) perception of the effectiveness of palliative radiotherapy; and (5) willingness to attend continuing medical education on radiation oncology. It was intended for self-completion and required 10–15 min to complete. The questionnaire was pilot tested on a group family physicians attending a primary care oncology update meeting in order to establish face validity, ease of completion, content, value and relevance, and completion time of 10–15 min. The survey sample frame of family physicians in the Eastern Ontario region was compiled using a combination of the Southam Canadian Medical Directory and the ORCC list of family physicians who had previously referred patients to the ORCC. The final survey sample frame consisted of 997 family physicians. In early 2002 the survey was mailed to a random sample of 400 of these family physicians. Knowledge about palliative radiotherapy was assessed by the number of correct responses to seven common indications for palliative radiotherapy as shown in Table 1. The questions were primarily used to determine knowledge about common indications for palliative radiotherapy rather than rigorously evaluating radiotherapy knowledge. The effectiveness of radiotherapy for the various situations was based on the opinions and experience of the authors as well as established published data [13]. Either ‘somewhat effective’ or ‘very effective’ were considered correct answers for scenarios 3 through 7 while ‘very effective’ was considered the only correct answer for scenarios 1 and 2. The expert panel decided that 6–7 out of 7 correct responses represented good knowledge about palliative radiotherapy, 4–5 out of 7 correct responses represented fair knowledge and 0–3 out of 7 correct responses represented poor knowledge. The completed surveys were collected and the responses were collated, and analyzed. A profile of family physicians that refer patients for palliative radiotherapy was constructed using multi-variate logistic regression modeling techniques.
Table 1 Questions evaluating palliative radiotherapy knowledge How effective do you consider radiotherapy for the following cancer related symptoms? (1) Painful bony metastases (2) Spinal cord compression (3) Hemoptysis (4) Hematuria (5) Painful local disease (6) Brain metastases (7) Airway obstruction Available choice of responses for each question Not effective Somewhat effective Very effective Donot know
Table 2 Demographics of responding family physicians Demographic variable Gender Female Male Year of graduation Mean Range Years practicing family medicine Mean Range CCFPa Yes No Practice setting Urban Rural Hospital admitting privileges Yes No a
Responders % (nZ172) 44 56 1980 1948–1998
18 years 0–40 years 64 36 64 36 52 48
CCFP, Certificant of Canadian College of Family.
Results Of the 400 surveys that were sent out, 55 were returned and deemed ineligible because the physicians did not practice family medicine, did not have cancer patients in their practice or had moved with no forwarding address. The survey return rate was 57% (227/400) and this represents approximately 23% of all family physicians in the region. A total of 172 completed surveys were received for an overall response rate for eligible respondents was 50% (172/345). General demographic information regarding the respondents is shown in Table 2. Almost all (97%) family physicians had seen cancer patients within the last month, with 85% looking after patients with advanced cancer. Eighty percent were involved in providing palliative care for their patients. Approximately 56% had referred patients for radiotherapy in the past and 53% had contacted a radiation oncology for advice in the past. Only 10% of all family physicians received formal radiotherapy education during their medical training and an additional 6% received some radiotherapy education after completing their medical training. The amount of training received was quite variable, ranging from one lecture to clinical rotations of over 1 year. Fig. 1 shows the knowledge about the indications for palliative radiotherapy among the responding family physicians. As indicated by Fig. 2, level of knowledge about the common indications for palliative radiotherapy was correlated with radiotherapy referral (P!0.01). Specifically, physicians most knowledgeable about the indications for palliative radiotherapy were also the most likely to have referred patients for radiotherapy in the past. This trend was noted even if ‘somewhat effective’ or ‘very effective’ were considered appropriate answers to the all the indications for palliative radiotherapy. Fig. 3 shows the responses among the physicians for each of the palliative situations for which radiotherapy could be
R.S. Samant et al. / Radiotherapy and Oncology 78 (2006) 101–106
103
Fig. 1. Knowledge of the indications for palliative radiotherapy physicians*. *Based on the number of correct responses ( ).
Fig. 3. Physicians’ perceptions on radiotherapy effectiveness for palliative conditions.
used. Although more than 50% correctly thought that radiotherapy was ‘very effective’ for painful bone and soft tissue metastases, less than 40% felt the same about the value of radiotherapy for other palliative situations such as brain metastases and spinal cord compression. In fact, only 14% thought that radiotherapy was ‘very effective’ for hemoptysis. Almost two-thirds of respondents were either unsure of the value of radiotherapy for hemoptysis and hematuria or thought it was ineffective, and almost half were uncertain about the value of radiotherapy for spinal cord compression or thought it was ineffective. When asked about factors affecting patient referral for palliative radiotherapy, 54% stated that uncertainty about benefits influence their referral ‘somewhat’ or ‘a lot’. Approximately 42% stated that life expectancy influenced their decision to refer patients with over one third of these physicians thinking that life expectancy should be 4 months or greater prior to referring patients for palliative radiotherapy. As shown in Table 3, other factors found to be strongly correlated (P!0.05) with patient referral for radiotherapy included a greater volume of cancer patients seen per month, increased frequency of providing palliative care, rural practice location and having contacted a radiation oncologist for advice in the past. Interestingly,
training in palliative care did not seem to influence referral for radiotherapy. Eighty-six percent of the physicians stated they would benefit from more education about radiation oncology and 87% would be willing to attend continuing medical education (CME) events on radiotherapy and its use in oncology. The preferred formats for learning were small group tutorials and workshops along with written materials.
Fig. 2. Relationship between knowledge of palliative radiotherapy indications and referral for radiotherapy.
Discussion The vast majority of family physicians surveyed were actively involved in the care of cancer patients. This has been documented in other studies, which show that family physicians provide much of the cancer care including palliative care to cancer patients in Canada [14,15] and elsewhere in the world [5,16]. Also, our respondents had little training in radiation oncology, which is consistent with the limited published literature in this area [17–20]. This situation is quite interesting when one considers the fact that family physicians continue to play a major and possibly increasing role in the management of cancer patients [14], and therefore, should be expected to have reasonable basic knowledge of oncology, including radiotherapy. The results of this study show that knowledge about the common indications for palliative radiotherapy among family physicians is less than ideal as many physicians were not aware of all of these indications. This should not be entirely surprising considering that less than 20% of the respondents had any formal education in the area of radiation oncology, either during their basic medical training or since completion of their training. Interestingly, in a study from Alberta (Canada), Barnes et al. [21] found very similar results regarding family physicians’ knowledge about the value for palliative radiotherapy. A recent American study found that physicians working in the hospice setting also recognize their educational deficiencies with regards to palliative radiotherapy knowledge [22]. The published literature indicates that undergraduate medical school training in oncology has been inadequate in the past
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Family doctors and palliative radiotherapy
Table 3 Comparison of family physicians referring and not referring for radiotherapy Variable Years in practice Mean Range Volume of cancer patients/month !5 6–10 O10 Frequency of providing palliative care Never Rarely Sometimes Often Training in palliative care Yes No Knowledge levela PoorZ0–3 FairZ4–5 GoodZ6–7 Accessibility of radiation oncologist Never tried Easy Difficult Practice setting Urban Rural a
Refer (nZ96) %
Not refer (nZ76) %
Test of association chi-square (c2) P!0. 05 unpaired t-test P!0.05
19.2 years 0–40
17.1 years 3–36
t-test(P)Z0.1205
39.6 31.2 29.2
58.0 33.0 9.0
(c2)PZ0.0169
1.0 3.2 29.5 66.3
3.9 30.3 35.5 30.3
(c2)P!0.0001
41.7 58.3
37.8 62.2
(c2)PZ0.6134
5.3 47.4 47.3
25.7 51.3 23.0
(c2)PZ0.0004
8.0 60.5 31.5
40.0 35.0 25.0
(c2)PZ0.0001
55.2 44.8
75.0 25.0
(c2)PZ0.0073
FP level of knowledge based on correctly answering indications for palliative radiotherapy; rangeZ0–7 correct answers.
[14,17,20,23] and although attempts at improving oncology education are being carried out, it remains uncertain if they are achieving their goals [24–26]. The fact that only half of respondents had ever contacted a radiation oncologist indicates that there is limited interaction occurring between cancer specialists and primary care physicians, and we believe that this needs to change. Other studies have also identified the need for better communication between oncologists and family physicians [16,21]. Although referrals for curative and adjuvant radiotherapy often come from specialists (such as medical oncologists, surgeons and hematologists), the majority of patients with advanced incurable cancer are followed by their family physician and, given the evidence for the benefit of palliative radiotherapy, we would expect more referrals from them for such treatment. This pattern of under referral may be partly explained by the finding that over half the family physicians surveyed stated that uncertainty about the benefits of palliative radiotherapy influenced their decision to some degree. As has been documented in another Canadian study [27], other factors, such as waiting times for consultation and treatment, were found to influence patient referral for radiotherapy among our respondents and have been reported separately [28]. The findings that physicians seeing more cancer patients and physicians involved in palliative care are more likely to
refer patients for radiotherapy seems obvious. We also found that rural physicians are more likely to provide more extensive cancer care for their patients. However, this is one of the first studies to demonstrate a direct relationship between a family physicians’ level of knowledge about the indications for palliative radiotherapy and referral of patients for radiotherapy. Therefore, it is important to ensure that better knowledge of radiation oncology is provided. The vast majority of the family physicians who responded to this survey indicated a need for and a desire to participate in ongoing education in this area. Residency training programs for family physicians need to emphasize the important role that they play in cancer care and must provide trainees with the basic knowledge and tools required to do this. The published literature shows that family physicians do not have enough training in oncology [23,25,29–32] and this is especially true for radiation oncology [20,21,24,31,33]. This deficiency is not just in the province of Ontario or within Canada but throughout the world [20,24]. The reasons for the lack of training are multifactorial [22,25,29,30,32]. However, the best ways in which to improve education about the practical aspects of oncology including radiotherapy are still debated [20,21,24,26,33]. Radiotherapy is such an important part of cancer treatment that family physicians need to have a basic understanding of this treatment
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modality. Therefore, initiatives to improve radiotherapy education are necessary. This may increase the number of appropriate referrals for radiotherapy, especially in the palliative setting. We are now in the process of developing ways to improve oncology knowledge in our region. The published literature on medical education [33–35] indicates that the most useful types of educational tools to help influence practice include use of local opinion leaders, development of relevant treatment guidelines, outreach visits and interactive education. Therefore, our plans include going into communities via a radiotherapy ‘road show’ type of format in order to give family physicians and other health care workers a clearer idea of exactly what types of services are available for their cancer patients and the evidence supporting their use. We also want to meet with local physician leaders and develop practical treatment guidelines for family physicians regarding the role of radiotherapy in the management of cancer patients. Tours of the Cancer Centre facility and possibly rotations through the Radiotherapy Department are also being considered. Our study has some limitations that could reduce the generalizability of our findings. This includes the response rate of 50% (which represents just under one quarter of family physicians in our region) that could lead to response bias since the responses received may not fairly reflect all family physicians. However, the response rate still compares favorably with other physician surveys [36]. The survey was self- reported and there is no clear documentation of radiotherapy referral. For example, if a physician claims that he or she had referred patient in the past for radiotherapy, this could not be independently verified. Finally, the evaluation of radiotherapy knowledge was not exhaustive and may not accurately reflect basic radiotherapy knowledge, and also did not use a validated instrument to measure palliative radiotherapy knowledge. However, the goal of the questions was to determine if the common indications for palliative radiotherapy were known to the family physicians and it was not our intent to perform a complete evaluation of radiotherapy knowledge.
Summary At present, many family physicians have less than optimal knowledge about the indications for palliative radiotherapy. Family physicians with insufficient knowledge of the indications for and effectiveness of palliative radiotherapy appear less likely to refer cancer patients for radiotherapy. Family physicians need to know more about radiotherapy so they can provide appropriate care for their cancer patients and know when to refer them for such treatment. To that end, radiation oncologists need to participate more in educating non-oncology physicians. They need to be more accessible to primary care physicians and have a greater profile within the communities they serve. Radiation oncologists need to think of themselves as ambassadors for their cancer centers and specifically advocates for the appropriate use of radiotherapy treatment. Our study indicates that family physicians are aware of their
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need to improve their radiotherapy knowledge and are keen to learn more.
* Corresponding author. Address: Ottawa Regional Cancer Centre, 503 Smyth Road, Ottawa, Ont., Canada K1H 1C4. E-mail address: [email protected] Received 17 June 2004; received in revised form 12 April 2005; accepted 10 November 2005; available online 5 December 2005
References [1] Ashby M. The role of radiotherapy in palliative care. J Pain Symptom Manage 1991;6:380–8. [2] Coia LR, Owen JB, Maher EJ, et al. Factors affecting treatment patterns of radiation oncology in the United State in the palliative treatment of cancer. Clin Oncol 1992;4:6–10. [3] Fine P. Palliative radiation therapy in end-of-life care. Am J Hosp Palliat Care 2002;19:166–70. [4] Perez C, Brady L, editors. Principles and practice of radiation oncology. 3rd ed. Am Fam Physician 1999:59(5):1183. [5] Tisdale BA. When to consider radiation therapy for your patient. Am Fam Physician 1999;59:1177–84. [6] Levitt SH, Leer JW. The role of radiotherapy in Sweden—a landmark study by the Swedish council on technology assessment in health care (editorial). Acta Oncol 1996;35: 965–6. [7] MacKillop WJ, Groome PA, Zhang-Salomons J, et al. Does a centralized radiotherapy system provide adequate access to care? Clin Oncol 1997;15:1261–71. [8] American College of Radiology, 1991. Radiation oncology in integrated cancer management: report of the inter-society council for radiation oncology. Reston, VA: American College of Radiology; Current Oncology 1991;9(1). [9] Mackillop WJ, Zhou S, Groome P, et al. Changes in the use of radiotherapy in Ontario 1984–1995. Int J of Radiat Oncol Biol Phys 1999;44:355–62. [10] Tyldesley S, Zhang-Salomons J, Groome PA, et al. Association between age and the utilization of radiotherapy in Ontario. Int J Radiat Oncol Biol Phys 2000;47:469–80. [11] Samant RS, Roberts GH, Dunscombe PB. Case-costing of palliative radiotherapy: a canadian single-institution perspective. Curr Oncol 2002;9:20–6. [12] Huang J, Zhou S, Groome P, et al. Factors affecting the use of palliative radiotherapy in Ontario. J Clin Oncol 2001;19:137–44. [13] Kagan AR, Powers WE, Ratanatharathorn V, Janjan N. In: Perez CA, Brady L, (eds.) Principles and practice of radiation oncology, 3rd ed. Philadelphia, PA: Lippincott–Raven Publishers; 1998. p. 2187–257. [14] Dworkind M, Shvartzman P, Adler PSJ, et al. Urban family physicians and the care of cancer patients. Can Fam Physician 1994;40:47–50. [15] McWhinney IR, Hoddinott SN, Bass MJ, et al. Role of the family physician in the care of cancer patients. Can Fam Physician 1990;36:2183–6. [16] Wakefield MA, Beilby J, Ashby MA. General practitioners and palliative care. Palliat Med 1993;7:117–26. [17] Cellerino R, Graziano F, Piga A, et al. The teaching of clinical oncology in Italian medical schools: a survey among teachers and students. Ann Oncol 1993;4:717–21. [18] Mortimer JE, Bartlett NL. Assessment of knowledge about cancer pain management by physicians in training. J Pain Symptom Manage 1997;14:21–8. [19] Skolnick AA. New study suggests radiation often underused for palliation. J Am Med Assoc 1998;279:343–4.
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Family doctors and palliative radiotherapy
[20] Smith WT, Tattersal MH, Irwig LM, et al. Undergraduate education about cancer. Eur J Cancer 1991;27:1448–53. [21] Barnes EA, Hanson J, Neumann CM, et al. Communication between primary care physicians and radiation oncologists regarding patients with cancer treated with palliative radiotherapy. J Clin Oncol 2000;18:2902–7. [22] Lutz S, Spence C, Chow E, et al. Survey on use of palliative radiotherapy in hospice care. J Clin Oncol 2004;22:3581–6. [23] Ramakrishnan S, Bolger JJ, Dunn KS, et al. Undergraduate medical teaching in departments of oncology in the United Kingdom: a questionnaire survey. J Cancer Educ 1993;8:25–30. [24] Barton MB, Simons RG. A survey of cancer curricula in Australian and New Zealand medical schools in 1997. Oncology Education Committee of the Australian Cancer Society. Med J Aust 1999;170:199–200. [25] Piga A, Graziano F, Zahra G, et al. Attitudes of non-oncology physicians on dealing with cancer patients. A survey based on clinical scenarios in Ancona province, central Italy. Tumori 1996;82:423–9. [26] Zapka JG, Luckmann R, Sulsky SI, et al. Cancer control knowledge, attitudes, and perceived skills among medical students. J Cancer Educ 2000;15:73–8. [27] Samant R, Fitzgibbon E, Meng J, Graham I. Identifying barriers to palliative radiotherapy referral. Radiother Oncol 2003;69: S25 [abstract].
[28] Brincker H. Undergraduate oncology education in Scandinavia. J Cancer Educ 1988;3:97–101. [29] Ravaud A, Hoerni B, Becouarn Y, et al. A survey in general practice about undergraduate cancer education: results from Gironde (France). J Cancer Educ 1991;6:153–7. [30] Samant R. Palliative care educational needs of family physicians. J Palliat Care 2001;17:227–80. [31] Tattersall MH, Langlands AO, Smith W, et al. Undergraduate education about cancer. A survey of clinical oncologists and clinicians responsible for cancer teaching in Australian medical schools. Eur J Cancer 1993;29A:1639–42. [32] Samant R. Palliative care educational needs of family physicians. J Palliat Care 2001;17:277–80. [33] Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care 2001;39:112–45. [34] Helwig A, Bower D, Wolff M, et al. Residents find clinical practice guidelines valuable as educational and clinical tools. Fam Med 1998;30:431–5. [35] Tracey J, Rodwell P, Clearwater G. Development and evaluation of the rural trauma and emergency care roadshow. N Z Med J 1999;112:144–7. [36] Guadagnoli E, Cunningham S. The effects of nonresponse and late response on a survey of physician attitudes. Eval Health Prof 1989;12:318–28.