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Palliative radiotherapy treatment for bone metastases: Patients’ treatment preferences
Proceedings of the 46th Annual ASTRO Meeting
were new to the TSRCC and were referred for palliative treatment of bone (70%) or CNS (14%) metastases. The number of cases referred to the RRRP increased from just over 200 cases annually in the first three years, to ⬃500 cases per year in the last 5 years. The dose fractionation for bone metastases was 8 Gy / 1 Fr in 31%, 20 Gy / 5 Fr in 29%, 30 Gy / 10 Fr in 24%, other 6%. Almost ninety percent were seen within 2 weeks of referral (38% within one week). Eighty five percent were simulated on the same day as their consultation, and sixty percent started their radiotherapy treatment on the day of their consultation visit. Conclusions: Over the past eight years the number of cases referred to the RRRP annually has doubled. We were able to achieve and maintain our goals of seeing the majority of patients in consultation, simulate and treat them within 2 weeks of their referral.
2377
Reasons for Poor Accrual in Palliative Radiotherapy (RT) Research Studies
E. R. Sinclair,1 D. Lee,1 L. Holden,1 V. Yau,1 N. Bradley,1 C. Danjoux,1,2 E. Chow1,2 Radiation Therapy, Toronto Sunnybrook Regional Cancer Centre, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada
1
Purpose/Objective: Recruiting cancer patients with advanced disease into research studies has been difficult. Our main objective was to examine the accrual rate into research studies and to explore the reasons for poor accrual. Secondly we wanted to look at the literature around palliative accrual and see if we were on par with other institutions who dealt with patients with advanced disease. Materials/Methods: Patients referred to the Rapid Response Radiotherapy Program (RRRP) and the Bone Metastases Clinic (BMC) at the Toronto Sunnybrook Regional Cancer Center were followed prospectively from March 2001 till August 2003. These patients were referred for consideration of palliative radiotherapy for their symptomatic metastases. Each patient was considered for ongoing research studies at the time of consultation. The accrual rates and the reasons for non-accrual were prospectively collected. Results: A total of 715 patients ( 367 males and 348 females) were seen in the study period. The median age was 67 (range 21 to 95). The primary sites of cancer were : Breast 161 (23%); prostate 115 (16%); lung 238 (33%); GI 57 (8%); renal cell 35 (5%); unknown primary 44 (6%); and others 65 (9%). The reasons for consultation included ; bone metastases 365 (51%); brain metastases 135 (19%); mass 27 (4%); spinal cord compression 22 (3%); fractures 29 (4%); shortness of breath 24 (3%); bleeding 13 (2%); and others 100 (14%). Only 97 patients (14%) were entered into research studies. Among 618 non-accrual patients the reasons for non-accrual were : 160 (26%) did not fit the eligibility criteria of the studies available; 200 (32%) declined to participate; 172 (28%) were not offered radiation treatment at that time; 39 (6%) could not participate because of a language barrier; 30 (5%) were too sick or too emotional or too confused; and 17 (3%) were excluded because the consultant radiation oncologist did not consider them as potential good study patients. In our secondary objective we discovered from the literature that our present accrual figures were about average in the palliative setting (10%). Conclusions: The main reasons for the poor accrual rates were shown to be that patients who did not fit into the eligibility criteria, patients who simply declined to take part or did not go on for radiation treatment at that time. The language barrier also contributed to non-accrual. We felt that it is important for the research investigators to take these reasons into consideration when planning new studies in order to improve their accrual rates. Palliative RT studies should be designed for the palliative population with realistic eligibility criteria and be of an appropriate (shorter) duration.
2378
Palliative Radiotherapy Treatment for Bone Metastases: Patients’ Treatment Preferences
E. F. Szumacher, E. Franssen, H. Llewellyn-Thomas, G. DeBoer, E. Chow, C. Danjoux, C. Hayter, L. Andersson, E. Barnes, L. Holden Rapid Response Radiotherapy Program, Bone Metastases Site Group, Dept. of Rad. Onc., Toronto Sunnybrook Regional Cancer Centre, Toronto, ON, Canada Purpose/Objective: Background: Palliative radiotherapy for bone pain is significant given the number of patients involved. In studies investigating palliative radiotherapy for bone metastasis, there is a marked paucity of input from patients. The majority of outcome measures in those studies mostly focused on pain intensity. Patients priorities, in terms of treatment and health care outcomes, have not been extensively examined. Purpose: 1.To determine the proportion of patients who would like to participate in the decision-making process involving palliative radiotherapy for bone pain. 2.To determine patients choice of palliative radiotherapy regimen (2000cGy/5frs vs. 800cGy/1frc) for painful bone metastases. Materials/Methods: Eligible patients were approached and were given an informed medical consent. Patients decisional preferences were studied using a 5-statement preference instrument. For patients who prefer an active and collaborative role, the decision board was used to help them to decide which palliative radiotherapy regimen they would prefer. Factors influencing patients choices were studied using the visual analogue scale (VAS). Results: One hundred and one patients participated in this study, 55 females and 46 males. Roles of preferences were as follows: 30 active, 47 collaborative and 24 passive. Seventy-seven patients of active and collaborative group, participated in part 2 study investigating decisional preferences for treatment with palliative radiotherapy using 800cGy /1 or 2000cGy/5 fractions. Fifty-five patients choose 800cGy/1 fraction and only 17 patients choose 2000cGy in five fractions. Five patients out of 77 were either treated using different fractionation because of their radiation oncologists decision, or were not treated because of lack of symptoms. All seventy-two patients who participated in decisional preferences for palliative radiotherapy (part 2) received the treatment according to their choice.
S561
S562
I. J. Radiation Oncology
● Biology ● Physics
Volume 60, Number 1, Supplement, 2004
Conclusions: The majority of patients preferred to decide either by themselves or with radiation oncologists which treatment option they would prefer. An 800cGy/1-frc regimen was favored and was independent on the treated site. The convenience, overall quality of life, and the chances of bone fracture with each treatment plan were the most important factors influencing patients choice. The detailed analysis of this study including patients demographics, as well as the factors influencing patients decisional preferences between one single and five fractions of palliative radiotherapy will be presented at the meeting.
2379
A Quantitative Portal Imaging Assessment of Set-up Discrepancies During Radiation Therapy for Spinal Metastases
D. Easton, A. Vavda, F. Cops, C. Goodridge, G. Leon, S. Scott Radiation Therapy, Princess Margaret Hospital, Toronto, ON, Canada Purpose/Objective: At PMH, radiation therapy (RT) for spinal metastases constitutes 15% of the palliative workload. A retrospective analysis of imaging data for posterior direct spinal R.T.(with patients in a supine position) revealed that 55% of 60 cases reviewed required lateral adjustment prior to treatment. The introduction of a modified technique incorporating lateral set-up tattoos improved the rate of required adjustment to 17% of the 60 patients accrued to the study. Materials/Methods: The adjustments required were made by the treatment therapist, after daily pretreatment portal imaging. All portal images were captured and saved for further review. A quantitative assessment of the magnitude of adjustment required was undertaken by utilizing image- matching technology available within the imaging systems. Each rejected image was analyzed for both groups of 60 patients. The magnitude of each shift required was measured accurately to the nearest millimeter. Patient information was collected at the time of simulation. The mental state and ECOG performance status of each patient was assessed. A questionnaire was completed for Pain Score and Body Mass Index. This data was collated to produce profiles for each patient. Results: The data on the required shifts statistically verifies the validity of the modified technique with respect to the patient population in which set-up discrepancies occur. In the retrospective group the range of lateral adjustment was 7mm to 30mm, with an average of 14mm. For the modified technique group of patients the range was 6mm to 15mm, with an average of 9mm. The patient profile information collected will be correlated with the data on required shifts. Conclusions: Use of this technique has improved reproducibility and reduced the magnitude of potential set-up error significantly. For this RT technique lateral set-up tattoos should be incorporated as a standard requirement. Daily pre-portal imaging of this patient population is extremely desirable. If pre-portal imaging is unavailable, a wider treatment field (current standard is 8.0cm) may merit consideration for patients whose assessed profile establishes an increased risk of set-up discrepancy.
2380
Decreased Palliative Radiotherapy Referrals as Related to Patterns of Treatment of Symptomatic Bone Metastasis in a Community Hospital Setting
S. Lutz, J. Ashworth, M. Kerr Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH Purpose/Objective: Palliative care constitutes a large part of the workload of any radiotherapy department, though few studies report the percent of patients consulted for symptomatic metastasis. One review from a large academic center revealed that 38% of consultations from 1978 to 1998 were sent for palliation, with treatment of bone metastasis constituting 14% of all radiotherapy consults.(1) We examined the palliative care referral patterns for a community radiotherapy department in a rural locale. Materials/Methods: A retrospective chart review examined palliative radiotherapy referrals to the Department of Radiation Therapy at the Blanchard Valley Regional Cancer Center for the calendar years 1997, 2000, and 2003. All charts were surveyed, and the consults were deemed palliative if the patient was consulted for symptomatic metastasis. The cases were subdivided by whether the metastasis involved bone, brain, lymph nodes, soft tissue, or other metastatic site. Bone lesions were further characterized as having resulted from primary tumor in the prostate, lung, breast, or other primary site. Changes in consultation rates over time were statistically analyzed using the chi-square method. Results: The total numbers of consultations seen in 1997, 2000, and 2003 were 266, 284, and 304, respectively. The percentage of palliative cases fell between the three time periods, mostly from a decrease in the number of patients sent for palliation of bone and brain metastasis (p ⫽ n.s). When divided by site of primary disease, the rate of patients consulted for treatment of bone metastasis for 1997, 2000, and 2003, respectively, was: lung 4.5%, 4.9%, 3.3%; breast 1.9%, 3.5%, 2.3%; prostate 3.0%, 1.8%, 0%; and other primary sites 4.9%; 2.8%, and 5.3%. Conclusions: Radiotherapy provides important palliative relief in many clinical settings, and we document the rate of palliative care provided in one community, hospital-based center. While acknowledging that many patients with locally advanced disease, alone, have a poor prognosis and may suffer significant symptoms, we limited our analysis to referrals sent for radiotherapy to sites of metastatic disease. This distinction might explain why the percentage of palliative cases is lower than those from previous reports. The percentage of patients treated for symptomatic bone metastasis in 1997 does mirror previous data, though in our facility the percentage of patients with bone metastasis has declined. This trend seems to be related to fewer treatments of patients with symptomatic bone metastasis from lung and prostate cancer. Interestingly, previous data showed an increase over time in the percentage of lung cancer patients sent for palliative radiotherapy of bone metastasis, though that data did not extend beyond 1998.(1) One may speculate that patients are experiencing lower rates of metastatic disease because of early detection and cure of primary disease or because of better control of advanced bone disease with agents such as bisphosphonates, which have increased in use over this time period. The radiotherapy community needs also to continue to educate referring physicians about the efficacy and low side-effect rates of external beam treatment for symptomatic bone metastasis.(2)(table 1).
were new to the TSRCC and were referred for palliative treatment of bone (70%) or CNS (14%) metastases. The number of cases referred to the RRRP increased from just over 200 cases annually in the first three years, to ⬃500 cases per year in the last 5 years. The dose fractionation for bone metastases was 8 Gy / 1 Fr in 31%, 20 Gy / 5 Fr in 29%, 30 Gy / 10 Fr in 24%, other 6%. Almost ninety percent were seen within 2 weeks of referral (38% within one week). Eighty five percent were simulated on the same day as their consultation, and sixty percent started their radiotherapy treatment on the day of their consultation visit. Conclusions: Over the past eight years the number of cases referred to the RRRP annually has doubled. We were able to achieve and maintain our goals of seeing the majority of patients in consultation, simulate and treat them within 2 weeks of their referral.
2377
Reasons for Poor Accrual in Palliative Radiotherapy (RT) Research Studies
E. R. Sinclair,1 D. Lee,1 L. Holden,1 V. Yau,1 N. Bradley,1 C. Danjoux,1,2 E. Chow1,2 Radiation Therapy, Toronto Sunnybrook Regional Cancer Centre, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada
1
Purpose/Objective: Recruiting cancer patients with advanced disease into research studies has been difficult. Our main objective was to examine the accrual rate into research studies and to explore the reasons for poor accrual. Secondly we wanted to look at the literature around palliative accrual and see if we were on par with other institutions who dealt with patients with advanced disease. Materials/Methods: Patients referred to the Rapid Response Radiotherapy Program (RRRP) and the Bone Metastases Clinic (BMC) at the Toronto Sunnybrook Regional Cancer Center were followed prospectively from March 2001 till August 2003. These patients were referred for consideration of palliative radiotherapy for their symptomatic metastases. Each patient was considered for ongoing research studies at the time of consultation. The accrual rates and the reasons for non-accrual were prospectively collected. Results: A total of 715 patients ( 367 males and 348 females) were seen in the study period. The median age was 67 (range 21 to 95). The primary sites of cancer were : Breast 161 (23%); prostate 115 (16%); lung 238 (33%); GI 57 (8%); renal cell 35 (5%); unknown primary 44 (6%); and others 65 (9%). The reasons for consultation included ; bone metastases 365 (51%); brain metastases 135 (19%); mass 27 (4%); spinal cord compression 22 (3%); fractures 29 (4%); shortness of breath 24 (3%); bleeding 13 (2%); and others 100 (14%). Only 97 patients (14%) were entered into research studies. Among 618 non-accrual patients the reasons for non-accrual were : 160 (26%) did not fit the eligibility criteria of the studies available; 200 (32%) declined to participate; 172 (28%) were not offered radiation treatment at that time; 39 (6%) could not participate because of a language barrier; 30 (5%) were too sick or too emotional or too confused; and 17 (3%) were excluded because the consultant radiation oncologist did not consider them as potential good study patients. In our secondary objective we discovered from the literature that our present accrual figures were about average in the palliative setting (10%). Conclusions: The main reasons for the poor accrual rates were shown to be that patients who did not fit into the eligibility criteria, patients who simply declined to take part or did not go on for radiation treatment at that time. The language barrier also contributed to non-accrual. We felt that it is important for the research investigators to take these reasons into consideration when planning new studies in order to improve their accrual rates. Palliative RT studies should be designed for the palliative population with realistic eligibility criteria and be of an appropriate (shorter) duration.
2378
Palliative Radiotherapy Treatment for Bone Metastases: Patients’ Treatment Preferences
E. F. Szumacher, E. Franssen, H. Llewellyn-Thomas, G. DeBoer, E. Chow, C. Danjoux, C. Hayter, L. Andersson, E. Barnes, L. Holden Rapid Response Radiotherapy Program, Bone Metastases Site Group, Dept. of Rad. Onc., Toronto Sunnybrook Regional Cancer Centre, Toronto, ON, Canada Purpose/Objective: Background: Palliative radiotherapy for bone pain is significant given the number of patients involved. In studies investigating palliative radiotherapy for bone metastasis, there is a marked paucity of input from patients. The majority of outcome measures in those studies mostly focused on pain intensity. Patients priorities, in terms of treatment and health care outcomes, have not been extensively examined. Purpose: 1.To determine the proportion of patients who would like to participate in the decision-making process involving palliative radiotherapy for bone pain. 2.To determine patients choice of palliative radiotherapy regimen (2000cGy/5frs vs. 800cGy/1frc) for painful bone metastases. Materials/Methods: Eligible patients were approached and were given an informed medical consent. Patients decisional preferences were studied using a 5-statement preference instrument. For patients who prefer an active and collaborative role, the decision board was used to help them to decide which palliative radiotherapy regimen they would prefer. Factors influencing patients choices were studied using the visual analogue scale (VAS). Results: One hundred and one patients participated in this study, 55 females and 46 males. Roles of preferences were as follows: 30 active, 47 collaborative and 24 passive. Seventy-seven patients of active and collaborative group, participated in part 2 study investigating decisional preferences for treatment with palliative radiotherapy using 800cGy /1 or 2000cGy/5 fractions. Fifty-five patients choose 800cGy/1 fraction and only 17 patients choose 2000cGy in five fractions. Five patients out of 77 were either treated using different fractionation because of their radiation oncologists decision, or were not treated because of lack of symptoms. All seventy-two patients who participated in decisional preferences for palliative radiotherapy (part 2) received the treatment according to their choice.
S561
S562
I. J. Radiation Oncology
● Biology ● Physics
Volume 60, Number 1, Supplement, 2004
Conclusions: The majority of patients preferred to decide either by themselves or with radiation oncologists which treatment option they would prefer. An 800cGy/1-frc regimen was favored and was independent on the treated site. The convenience, overall quality of life, and the chances of bone fracture with each treatment plan were the most important factors influencing patients choice. The detailed analysis of this study including patients demographics, as well as the factors influencing patients decisional preferences between one single and five fractions of palliative radiotherapy will be presented at the meeting.
2379
A Quantitative Portal Imaging Assessment of Set-up Discrepancies During Radiation Therapy for Spinal Metastases
D. Easton, A. Vavda, F. Cops, C. Goodridge, G. Leon, S. Scott Radiation Therapy, Princess Margaret Hospital, Toronto, ON, Canada Purpose/Objective: At PMH, radiation therapy (RT) for spinal metastases constitutes 15% of the palliative workload. A retrospective analysis of imaging data for posterior direct spinal R.T.(with patients in a supine position) revealed that 55% of 60 cases reviewed required lateral adjustment prior to treatment. The introduction of a modified technique incorporating lateral set-up tattoos improved the rate of required adjustment to 17% of the 60 patients accrued to the study. Materials/Methods: The adjustments required were made by the treatment therapist, after daily pretreatment portal imaging. All portal images were captured and saved for further review. A quantitative assessment of the magnitude of adjustment required was undertaken by utilizing image- matching technology available within the imaging systems. Each rejected image was analyzed for both groups of 60 patients. The magnitude of each shift required was measured accurately to the nearest millimeter. Patient information was collected at the time of simulation. The mental state and ECOG performance status of each patient was assessed. A questionnaire was completed for Pain Score and Body Mass Index. This data was collated to produce profiles for each patient. Results: The data on the required shifts statistically verifies the validity of the modified technique with respect to the patient population in which set-up discrepancies occur. In the retrospective group the range of lateral adjustment was 7mm to 30mm, with an average of 14mm. For the modified technique group of patients the range was 6mm to 15mm, with an average of 9mm. The patient profile information collected will be correlated with the data on required shifts. Conclusions: Use of this technique has improved reproducibility and reduced the magnitude of potential set-up error significantly. For this RT technique lateral set-up tattoos should be incorporated as a standard requirement. Daily pre-portal imaging of this patient population is extremely desirable. If pre-portal imaging is unavailable, a wider treatment field (current standard is 8.0cm) may merit consideration for patients whose assessed profile establishes an increased risk of set-up discrepancy.
2380
Decreased Palliative Radiotherapy Referrals as Related to Patterns of Treatment of Symptomatic Bone Metastasis in a Community Hospital Setting
S. Lutz, J. Ashworth, M. Kerr Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH Purpose/Objective: Palliative care constitutes a large part of the workload of any radiotherapy department, though few studies report the percent of patients consulted for symptomatic metastasis. One review from a large academic center revealed that 38% of consultations from 1978 to 1998 were sent for palliation, with treatment of bone metastasis constituting 14% of all radiotherapy consults.(1) We examined the palliative care referral patterns for a community radiotherapy department in a rural locale. Materials/Methods: A retrospective chart review examined palliative radiotherapy referrals to the Department of Radiation Therapy at the Blanchard Valley Regional Cancer Center for the calendar years 1997, 2000, and 2003. All charts were surveyed, and the consults were deemed palliative if the patient was consulted for symptomatic metastasis. The cases were subdivided by whether the metastasis involved bone, brain, lymph nodes, soft tissue, or other metastatic site. Bone lesions were further characterized as having resulted from primary tumor in the prostate, lung, breast, or other primary site. Changes in consultation rates over time were statistically analyzed using the chi-square method. Results: The total numbers of consultations seen in 1997, 2000, and 2003 were 266, 284, and 304, respectively. The percentage of palliative cases fell between the three time periods, mostly from a decrease in the number of patients sent for palliation of bone and brain metastasis (p ⫽ n.s). When divided by site of primary disease, the rate of patients consulted for treatment of bone metastasis for 1997, 2000, and 2003, respectively, was: lung 4.5%, 4.9%, 3.3%; breast 1.9%, 3.5%, 2.3%; prostate 3.0%, 1.8%, 0%; and other primary sites 4.9%; 2.8%, and 5.3%. Conclusions: Radiotherapy provides important palliative relief in many clinical settings, and we document the rate of palliative care provided in one community, hospital-based center. While acknowledging that many patients with locally advanced disease, alone, have a poor prognosis and may suffer significant symptoms, we limited our analysis to referrals sent for radiotherapy to sites of metastatic disease. This distinction might explain why the percentage of palliative cases is lower than those from previous reports. The percentage of patients treated for symptomatic bone metastasis in 1997 does mirror previous data, though in our facility the percentage of patients with bone metastasis has declined. This trend seems to be related to fewer treatments of patients with symptomatic bone metastasis from lung and prostate cancer. Interestingly, previous data showed an increase over time in the percentage of lung cancer patients sent for palliative radiotherapy of bone metastasis, though that data did not extend beyond 1998.(1) One may speculate that patients are experiencing lower rates of metastatic disease because of early detection and cure of primary disease or because of better control of advanced bone disease with agents such as bisphosphonates, which have increased in use over this time period. The radiotherapy community needs also to continue to educate referring physicians about the efficacy and low side-effect rates of external beam treatment for symptomatic bone metastasis.(2)(table 1).