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Palliating Bone Mets at the End of Life: Are We Choosing Wisely?
S220
International Journal of Radiation Oncology Biology Physics
1112
Materials/Methods: All patients seen at a single institution who died between 10/1/2014 and 9/30/2015 (n Z 1187), had at least three evaluation and management visits within the last year of life (n Z 880), and had a cancer diagnosis (n Z 870) were included in this study. Records from claims data (clinical, demographics) and RT treatment (start date, treatment intent, ICD9 code, number of fractions) were extracted and linked. Over the last 365 days of life, we evaluated RT utilization by intent (curative vs palliative) and by indications (ICD9). Aside from descriptions of clinical characteristics, which were by patient, analyses were performed by radiated site. Results: Among 870 cancer patients, 280 (32.2%) underwent RT to 415 sites within the last 365 days of life (RT365). Utilization decreased to 23.3% and 8.2% in the last 180 and 30 days of life, respectively. RT365 patients were slightly younger at death (median, 61 vs 64 years) and had a higher proportion of lung (17.1% vs 10.5%), sarcoma (7.9% vs 2.9%), and transplant (11.1% vs 4.4%) disease groups. In the last 365 days of life, 25% of sites were radiated with curative intent. RT utilization for curative sites was constant across the last 365 days of life (12, 6, and 1 month(s) from death: 9.6%, 7.7%, and 7.7%, respectively). In contrast, RT for palliative sites increased more rapidly closer to death (12, 6, and 1 month(s) from death: 2.9%, 5.8%, and 14.8%, respectively). Based on ICD9 coding, treatment of bone metastases and utilization of single-fraction RT for bone metastases increased closer to death (Table 1). The originally planned RT treatment course was not completed in 31 of 311 (9.9%) palliative sites. Stopping treatment midcourse was higher among patients that started RT in the inpatient versus outpatient setting (13.6% vs 9%).
Palliating Bone Mets at the End of Life: Are We Choosing Wisely? A.S. Wallace, K.S. Keene, E. Kvale, C. Williams, M. Pisu, E. Partridge, J.B. Fiveash, and G. Rocque; University of Alabama at Birmingham, Birmingham, AL Purpose/Objective(s): The purpose of this study is to analyze general practice patterns and assess concordance with Choosing Wisely recommendations for consideration of no more than 10 fractions of palliative intent radiation for bone metastasis, with consideration for 1 fraction in those with limited prognosis. Materials/Methods: Medicare patients aged 65 years with bone metastasis from 12 cancer community networks affiliated with an academic center in Alabama, Mississippi, Georgia, Tennessee, and Florida with available dates of death were identified. Radiation (RT) was identified in 2012-2014, and survival information was available through 2015. Patients were eligible and identified using ICD-9(198.5) and CPT/HCPCS codes. Guideline concordance was defined as treatment duration of 1-10 fractions. Factors associated with utilization of RT (1, 2-10, 11+ fractions), including age, race, primary site, hospice enrollment, Charlson comorbidity index (0, 1, 2+), and center size (large 4000) were analyzed at the end of life. Results: In 3262 patients with bone metastasis, 540 (17%) were treated with RT, of which 425 (78.8%) had available dates of death. Median age at diagnosis was 73.1 (IQR 8.3), 89% were white, and 58% had Charlson comorbidity index of 2+. The top 4 primary sites were lung (39.5%), genitourinary (23.5%), gastrointestinal (10.8%), and breast (9.9%). Overall guideline concordance was 65.7%: 1 fraction in 36.0%, 2-10 in 29.7%, and 11+ fractions in 34.4%. Median survival from last fraction of RT to death was 169 days (IQR 312). While no patient factors were significant for utilization of shorter fractionation schemas, large centers were more likely to deliver shorter fractionation regimens (P Z 0.03). Although not significant, median survival was 149, 174, and 207 days for 1, 2-10, and 11+ fractions respectively. Survival after completion of radiation was 30 days and 90 days in 20%, and 36%, respectively. In patients with 30 day survival, 65% were treated with more than 1 fraction of radiation. Hospice enrollment was 67.5% for the entire cohort, and did not impact fractionation. In comparison to 1 fraction, 11+ fractions were associated with $2,280 increase in per patient cost to Medicare. Conclusion: While compliance was high overall with ASTRO Choosing Wisely recommendations, there remained a significant portion of patients who received a prolonged course of palliative radiation with survival < 30 days. There was no increase in utilization of shorter fractionation in the last 30 days of life, which may be indicative of poor physician prognostication. Author Disclosure: A.S. Wallace: Stock; Baxter, Baxalta, Johnson and Johnson, Shire PLC. K.S. Keene: None. E. Kvale: None. C. Williams: None. M. Pisu: None. E. Partridge: None. J.B. Fiveash: Research Grant; Varian Research Contract. Honoraria; Varian Research Contract. Travel Expenses; Varian Research Contract. G. Rocque: Research Grant; PackHealth, Carevive Systems, Genentech. Research Funding, Honoraria, Travel, Accommodations, Expenses; Medscape.
1113 Use of Radiation Within the Last Year of Life Among Cancer Patients Y.D. Tseng,1 N. Gouwens,2 S.S. Lo,1 L.M. Halasz,3 I. Mezheritsky,4 and E. Loggers4; 1University of Washington, Department of Radiation Oncology, Seattle, WA, 2Allen Institute for Brain Science, Seattle, WA, 3 University of Washington, Seattle, WA, 4Seattle Cancer Care Alliance, Seattle, WA Purpose/Objective(s): In a large single institution, we examined use of radiation (RT) within the last year of life. We hypothesized that as palliative RT (PRT) has been well studied in patients with life expectancies of 6 weeks or longer, PRT use would be constant over the remaining year of life, except for the last 30 days, when use would decline.
Conclusion: Among a cohort of cancer patients regularly seen and treated at a single, high-volume institution, PRT appears to be disproportionately utilized closer to death with an increasing proportion of radiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer toward the end of life. As patients with very poor prognosis (e.g. 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. Author Disclosure: Y.D. Tseng: Employee; Allen Brain Science Institute. N. Gouwens: Employee; University of Washington. S.S. Lo: Research Grant; Elekta AB. Travel Expenses; Elekta AB, Accuray. Promote radiation oncology in various capacities; American College of Radiology. Organizing refresher courses in radiation oncology in RSNA annual meeting; Radiological Society of North America (RSNA). Establishing appropriateness criteria for radiotherapy for bone metastases. L.M. Halasz: Research Grant; Fred Hutch/University of Washington Cancer Consortium. I. Mezheritsky: None. E. Loggers: None.
Abstract 1113; Table 1 Days from death (n Z sites) 30 days (n Z 47) Proportion of palliative sites treated for bone metastases (ICD9 198.5) Number of fractions prescribed 1 >1 to 5 >5 to 10 >10 to 15
31-180 days (n Z 164)
181-365 days (n Z 100)
48.9%
38.4%
37.0%
52.2% 26.1% 17.4% 4.3%
28.6% 38.1% 30.2% 3.2%
32.4% 32.4% 24.3% 10.8%
1114 Ethical Issues in the Care of Patients Referred for Palliative Radiation Therapy D. Yerramilli,1 G. Parker,1 V. LeBaron,2 M.S. Krishnan,3 L.M. Hertan,4 A. Spektor,5 R. Shiloh,3 S. Skamene,6 and T.A. Balboni3; 1Dana-Farber/ Brigham and Women’s Cancer Center, Boston, MA, 2University of Virginia, Charlottesville, VA, 3Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA, 4University of Pennsylvania, Philadelphia, PA,
International Journal of Radiation Oncology Biology Physics
1112
Materials/Methods: All patients seen at a single institution who died between 10/1/2014 and 9/30/2015 (n Z 1187), had at least three evaluation and management visits within the last year of life (n Z 880), and had a cancer diagnosis (n Z 870) were included in this study. Records from claims data (clinical, demographics) and RT treatment (start date, treatment intent, ICD9 code, number of fractions) were extracted and linked. Over the last 365 days of life, we evaluated RT utilization by intent (curative vs palliative) and by indications (ICD9). Aside from descriptions of clinical characteristics, which were by patient, analyses were performed by radiated site. Results: Among 870 cancer patients, 280 (32.2%) underwent RT to 415 sites within the last 365 days of life (RT365). Utilization decreased to 23.3% and 8.2% in the last 180 and 30 days of life, respectively. RT365 patients were slightly younger at death (median, 61 vs 64 years) and had a higher proportion of lung (17.1% vs 10.5%), sarcoma (7.9% vs 2.9%), and transplant (11.1% vs 4.4%) disease groups. In the last 365 days of life, 25% of sites were radiated with curative intent. RT utilization for curative sites was constant across the last 365 days of life (12, 6, and 1 month(s) from death: 9.6%, 7.7%, and 7.7%, respectively). In contrast, RT for palliative sites increased more rapidly closer to death (12, 6, and 1 month(s) from death: 2.9%, 5.8%, and 14.8%, respectively). Based on ICD9 coding, treatment of bone metastases and utilization of single-fraction RT for bone metastases increased closer to death (Table 1). The originally planned RT treatment course was not completed in 31 of 311 (9.9%) palliative sites. Stopping treatment midcourse was higher among patients that started RT in the inpatient versus outpatient setting (13.6% vs 9%).
Palliating Bone Mets at the End of Life: Are We Choosing Wisely? A.S. Wallace, K.S. Keene, E. Kvale, C. Williams, M. Pisu, E. Partridge, J.B. Fiveash, and G. Rocque; University of Alabama at Birmingham, Birmingham, AL Purpose/Objective(s): The purpose of this study is to analyze general practice patterns and assess concordance with Choosing Wisely recommendations for consideration of no more than 10 fractions of palliative intent radiation for bone metastasis, with consideration for 1 fraction in those with limited prognosis. Materials/Methods: Medicare patients aged 65 years with bone metastasis from 12 cancer community networks affiliated with an academic center in Alabama, Mississippi, Georgia, Tennessee, and Florida with available dates of death were identified. Radiation (RT) was identified in 2012-2014, and survival information was available through 2015. Patients were eligible and identified using ICD-9(198.5) and CPT/HCPCS codes. Guideline concordance was defined as treatment duration of 1-10 fractions. Factors associated with utilization of RT (1, 2-10, 11+ fractions), including age, race, primary site, hospice enrollment, Charlson comorbidity index (0, 1, 2+), and center size (large 4000) were analyzed at the end of life. Results: In 3262 patients with bone metastasis, 540 (17%) were treated with RT, of which 425 (78.8%) had available dates of death. Median age at diagnosis was 73.1 (IQR 8.3), 89% were white, and 58% had Charlson comorbidity index of 2+. The top 4 primary sites were lung (39.5%), genitourinary (23.5%), gastrointestinal (10.8%), and breast (9.9%). Overall guideline concordance was 65.7%: 1 fraction in 36.0%, 2-10 in 29.7%, and 11+ fractions in 34.4%. Median survival from last fraction of RT to death was 169 days (IQR 312). While no patient factors were significant for utilization of shorter fractionation schemas, large centers were more likely to deliver shorter fractionation regimens (P Z 0.03). Although not significant, median survival was 149, 174, and 207 days for 1, 2-10, and 11+ fractions respectively. Survival after completion of radiation was 30 days and 90 days in 20%, and 36%, respectively. In patients with 30 day survival, 65% were treated with more than 1 fraction of radiation. Hospice enrollment was 67.5% for the entire cohort, and did not impact fractionation. In comparison to 1 fraction, 11+ fractions were associated with $2,280 increase in per patient cost to Medicare. Conclusion: While compliance was high overall with ASTRO Choosing Wisely recommendations, there remained a significant portion of patients who received a prolonged course of palliative radiation with survival < 30 days. There was no increase in utilization of shorter fractionation in the last 30 days of life, which may be indicative of poor physician prognostication. Author Disclosure: A.S. Wallace: Stock; Baxter, Baxalta, Johnson and Johnson, Shire PLC. K.S. Keene: None. E. Kvale: None. C. Williams: None. M. Pisu: None. E. Partridge: None. J.B. Fiveash: Research Grant; Varian Research Contract. Honoraria; Varian Research Contract. Travel Expenses; Varian Research Contract. G. Rocque: Research Grant; PackHealth, Carevive Systems, Genentech. Research Funding, Honoraria, Travel, Accommodations, Expenses; Medscape.
1113 Use of Radiation Within the Last Year of Life Among Cancer Patients Y.D. Tseng,1 N. Gouwens,2 S.S. Lo,1 L.M. Halasz,3 I. Mezheritsky,4 and E. Loggers4; 1University of Washington, Department of Radiation Oncology, Seattle, WA, 2Allen Institute for Brain Science, Seattle, WA, 3 University of Washington, Seattle, WA, 4Seattle Cancer Care Alliance, Seattle, WA Purpose/Objective(s): In a large single institution, we examined use of radiation (RT) within the last year of life. We hypothesized that as palliative RT (PRT) has been well studied in patients with life expectancies of 6 weeks or longer, PRT use would be constant over the remaining year of life, except for the last 30 days, when use would decline.
Conclusion: Among a cohort of cancer patients regularly seen and treated at a single, high-volume institution, PRT appears to be disproportionately utilized closer to death with an increasing proportion of radiated sites being bone metastases. This may be secondary to increased symptoms from advanced cancer toward the end of life. As patients with very poor prognosis (e.g. 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. Author Disclosure: Y.D. Tseng: Employee; Allen Brain Science Institute. N. Gouwens: Employee; University of Washington. S.S. Lo: Research Grant; Elekta AB. Travel Expenses; Elekta AB, Accuray. Promote radiation oncology in various capacities; American College of Radiology. Organizing refresher courses in radiation oncology in RSNA annual meeting; Radiological Society of North America (RSNA). Establishing appropriateness criteria for radiotherapy for bone metastases. L.M. Halasz: Research Grant; Fred Hutch/University of Washington Cancer Consortium. I. Mezheritsky: None. E. Loggers: None.
Abstract 1113; Table 1 Days from death (n Z sites) 30 days (n Z 47) Proportion of palliative sites treated for bone metastases (ICD9 198.5) Number of fractions prescribed 1 >1 to 5 >5 to 10 >10 to 15
31-180 days (n Z 164)
181-365 days (n Z 100)
48.9%
38.4%
37.0%
52.2% 26.1% 17.4% 4.3%
28.6% 38.1% 30.2% 3.2%
32.4% 32.4% 24.3% 10.8%
1114 Ethical Issues in the Care of Patients Referred for Palliative Radiation Therapy D. Yerramilli,1 G. Parker,1 V. LeBaron,2 M.S. Krishnan,3 L.M. Hertan,4 A. Spektor,5 R. Shiloh,3 S. Skamene,6 and T.A. Balboni3; 1Dana-Farber/ Brigham and Women’s Cancer Center, Boston, MA, 2University of Virginia, Charlottesville, VA, 3Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA, 4University of Pennsylvania, Philadelphia, PA,