Characteristics of urgent palliative cancer care consultations encountered by radiation oncologists
Background Palliative radiation therapy (PRT) is often used in patients with advanced cancers who require urgent consultation.
Objective To report on the characteristics of urgent palliative issues encountered by radiation oncologists.
Methods Patterns of presentation in 162 consultations for urgent PRT at 3 centers were prospectively evaluated from May 19 to September 26, 2014. A survey of palliative care issues, including assessment of reasons for urgent consultation, disease presentation, characteristics, and sites of RT delivery, was completed by physicians and/or nurse practitioners. The response rate was 86%, with 140 of 162 responses received.
Results The median age of the patients was 63 years, with 80% older than 50 years. 56% were men, and 44% were women. 57% had an Eastern Cooperative Oncology Group Performance Status of 0-1. Primary cancer diagnoses were lung (28%), breast (13%), prostate (10%), melanoma (10%), sarcoma (7%), and others (32%). The main reasons for PRT consult were pain (57%), brain metastases (29%), and cord compression (13%). The most common presenting symptoms were pain (69%), neurologic symptoms (51%), and fatigue (49%). Patients were seen throughout the trajectory of their care as follows: 63% at the time of an established metastasis, 19% at the time of their initial diagnosis continuing further cancer therapies, and 16% before hospice care without further anticancer therapy.
Limitations Single institution and descriptive
Conclusions PRT occurs across the spectrum of advanced cancer, from initial diagnosis to end of life, and is used in a range of urgent oncologic issues, mostly painful metastases, followed by brain metastases and cord compression. Radiation oncologists manage cancer-related symptoms such as pain, neurologic symptoms, and fatigue.
Accepted for publication July 17, 2018
Correspondence Muhammed M Fareed, MD; mmfareed@bwh.harvard.edu
Disclosures The authors report no disclosures or conflicts of interest.
Citation JCSO 2018;16(4):e193-e199
©2018 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0415
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Palliative radiation therapy (PRT) plays a major role in the management of incurable cancers. Study findings have demonstrated the efficacy of using PRT in treating tumor-related bone pain,1 brain metastases and related symptoms,2 thoracic disease-causing hemoptysis or obstruction,3 gastrointestinal involvement causing bleeding and/or obstruction,4 and genitourinary and/or gynecologic involvement causing bleeding.5,6
PRT accounts for between 30% and 50% of courses of radiotherapy delivered.3 These courses of RT typically require urgent evaluation since patients are seen because of new and/or progressive symptoms that give cause for concern. The urgency of presentation requires radiation oncologists and the departments receiving these patients to be equipped to manage these cases efficiently and effectively. Furthermore, the types of cases seen, including PRT indications and related symptoms requiring management, inform the training of radiation oncology physicians as well as nursing and other clinical staff. Finally, characterizing the types of urgent PRT cases that are seen can also guide research and quality improvement endeavors for advanced cancer care in radiation oncology settings.
There is currently a paucity of data characterizing the types and frequencies of urgent PRT indications in patients who present to radiation oncology departments, as well as a lack of data detailing the related symptoms radiation oncology clinicians are managing. The aim of this study was to characterize the types and frequencies of urgent PRT consultations and the related symptoms that radiation oncologists are managing as part of patient care.
,Methods
Based on national palliative care practice and national oncology care practice guidelines,7,8 we designed a survey to categorize the cancer-related palliative care issues seen by radiation oncologists. Physical symptoms, psychosocial issues, cultural consideration, spiritual needs, care coordination, advanced-care planning, goals of care, and ethical and legal issues comprised the 8 palliative care domains that we evaluated. A survey was developed and critically evaluated by 3 investigators (MK, VL, TB). Each palliative care domain was ranked by clinicians by its relevance (5-point Likert scale [range, 1-5]: 1, Not Relevant, to 5, Extremely Relevant) to the patient’s care point in radiation oncology. In addition, 31 palliative care subissues related to the primary domains were identified by clinicians based on their presence (Yes, No, Not Assessed). Clinicians were also asked whether the consulted patient’s metastatic cancer diagnosis was established (longer than 1 month) or new (within the last 1 month). In addition, clinicians noted whether the patient was returning to active oncologic care (eg, chemotherapy) or to no further anticancer therapies (eg, hospice care) after RT consultation and intervention (if deemed necessary).
The survey’s face and content validity, ease of completion, and time of completion was assessed by a panel of 7 clinicians with expertise in medical oncology, radiation oncology, palliative care, and/or survey construction. The survey was then sent in a sequential manner to 1 member of the panel at a time after incorporating each panel member’s initial comments. After each panel member’s review, the survey was edited until 2 consecutive panel members had no further suggestions for improvement.
After receiving approval from the institutional review boards of participating radiation oncology centers, we electronically surveyed radiation oncology clinicians who were conducting PRT consultations. From May 19 to September 26, 2014, all consultations were evaluated prospectively for consideration of PRT performed by a dedicated PRT service at 3 centers (a large academic cancer center and 2 participating clinicians at affiliated regional hospitals). The consultations for patients aged 18 years or older with incurable, metastatic cancers were considered eligible. The consulting clinician was e-mailed a survey for completion within 5 business days immediately after each PRT consult. Three reminders to complete the survey were sent during the 5–business-day interval. Over the entire study period, 162 consecutive patients were identified, resulting in 162 surveys being sent to 15 radiation oncology clinicians, including nurse practitioners, resident physicians, and attending physicians. Each clinician received a $25 gift card for participating, regardless of the number of surveys completed. In total, 140 of the 162 surveys were returned, resulting in a response rate of 86%.
The investigators then collected patient demographics (age, gender, race, marital status) and disease characteristics (primary cancer type, Eastern Cooperative Oncology Group Performance Status, reasons for urgent RT consult, physical symptoms requiring management at presentation, patient’s place in illness trajectory, and RT recommendation) pertaining to each completed survey from the electronic medical record. Urgent consultations were defined as any patients who needed to be seen on the same day or within a few days of the consult request.
The descriptive statistics of all these data were calculated in terms of frequencies and percentage of categorical variables. Chi-squared statistics, Fisher exact test, and nonparametric rank sum tests were applied to various categories to determine any statistically significant differences between groups.
