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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Our study provides an insight into urgent symptoms encountered by radiation oncology practitioners during their routine practice. Cancer-related pain remains the most common symptom requiring management. Given the frequency with which pain management is needed among PRT patients, this study highlights the need for radiation oncologists to be well trained in symptom management, particularly as the pain response to RT can often take several days. However, studies suggest that cancer-related pain is not frequently managed by radiation oncologists.9 For example, findings from an Italian study showed that the involvement of radiation oncologists in cancer pain management remains minimal compared with other medical professionals; during the treatment course, only half of the radiation oncologists implemented specific treatment for breakthrough pain.10 A nationwide survey in the United States implicated a number of barriers to adequate pain management, including poor assessment by the physician, reluctance in prescribing opioid analgesics, perceived excessive regulation, and patient reluctance to report pain.11 Notably, in a survey of the Radiation Therapy Oncology Group study physicians, 83% believed cancer patients with pain were undermedicated, and 40% reported that pain relief in their own practice setting was suboptimal. Furthermore, in the treatment plan, adjuvants and prophylactic side effect management were frequently not used properly.12 Education of radiation oncologists in pain assessment and management is key to overcome these barriers and to ensure adequate pain management and quality of life for patients in radiation oncology.
The next most common reason for which patients presented for palliative radiation oncology consultation was for central nervous system (CNS) metastatic disease, including brain metastases and spinal cord compression. Correspondingly, the next most common issue requiring management was neurologic symptoms. Management of CNS disease is becoming increasingly complex, and it benefits from multidisciplinary evaluation to guide optimal and personalized care for each patient, including medical oncology, radiation oncology, neurosurgery and/or orthopedic spine surgery, and palliative medicine. Treatment options include supportive care or corticosteroids alone, surgical resection, whole-brain RT, and/or radiosurgery or stereotactic RT alone. These treatment options are considered on the basis of global patient factors, such as prognosis, together with metastatic-site–specific factors, such as site-related symptoms and the number of metastatic diseases or the burden of the disease.13 For example, the use of the diagnosis-specific Graded Prognostic Assessment index to predict life expectancy can help tailor management of brain metastases based on performance status, age, number of brain metastases, extracranial metastases, and cancer type. Highlighting the complexity of this common PRT presentation, Tsao and colleagues showed that there was a lack of uniform agreement among radiation oncologists for common management issues in patients with brain metastatic disease.14
For metastatic spinal cord or cauda equina compression and the associated neurologic symptoms, initiation of immediate corticosteroids and implementation of local therapy within 24 hours of presentation is paramount,15 highlighting the need for rapid, comprehensive care decision-making for these patients. Treatment options that must be weighed include the potential benefit of upfront decompressive surgery, as supported by a randomized controlled trial by Patchell and colleagues16 for patients who are surgical candidates with true cord or cauda compression and have at least 1 neurologic symptom, a prognosis of ≥3 months, paraplegia of no longer than 48 hours, and no previous RT to the site or brain metastases. Compared with the RT alone, patients receiving surgery before RT had improved ambulatory status and overall survival. Hence, neurosurgical or orthopedic consultation should be standard in the evaluation of metastatic spinal cord or cauda equina compression patients. However, patients frequently do not meet these criteria, and corticosteroids and RT alone are considered. In addition to playing a role in surgical decision-making, prognosis also has a key role in decision-making about the RT fractionation. Short-course RT (8 Gy × 1) is as effectual as longer-course regimens (3 Gy × 10) in terms of motor function.17,18 However, more dose-intense or longer-course regimens, such as 3 Gy × 10, have been shown to have more durability beyond about 6 months and are therefore considered for intermediate to good prognosis.18 The common urgent presentation of CNS metastatic disease to radiation oncology clinics together with the complexity of management and urgency of care decision-making point to the need for dedicated structures of care for these patients in radiation oncology settings. For example, dedicated PRT programs, such as the Rapid Response Radiotherapy Program in Toronto and the Supportive and Palliative Radiation Oncology service in Boston, have demonstrated improved quality of care for patients being urgently evaluated for PRT.19
,Following management of pain and neurologic symptoms, clinicians were faced with managing fatigue in nearly half of the patients (49%). The prevalence of fatigue among cancer patients and its impact on quality of life20 highlight the need for this key symptom to be addressed throughout the continuum of cancer care. National Comprehensive Cancer Network guidelines provide a comprehensive framework for addressing cancer-related fatigue.7 However, cancer-related fatigue is a largely underreported, underestimated, and thus undertreated problem.20 In a nationwide survey of members of the American Society for Radiation Oncology, radiation oncologists reported being significantly less confident in managing fatigue compared with managing other common symptoms.21 Furthermore, in a national survey of radiation oncology trainees, 67% of respondents indicated that they were not at all minimally or somewhat confident in their ability to manage fatigue symptoms. The frequency of this symptom together with the demonstrated need for improved education in fatigue management point to a need for radiation oncology palliative educational structures to include dedicated emphasis on managing fatigue in addition to other commonly encountered symptoms, such as pain.
Patients evaluated for PRT are seen across the trajectory of their metastatic cancer diagnosis. In our study, patients presented at all stages in their advanced cancers. These include patients seen at the time of initial diagnosis of cancer as well as those seen near the end of life when end-of-life care planning was underway. The broad spectrum of timing of PRT care underscores that radiation oncologists must be prepared to handle generalist palliative care issues encountered throughout the trajectory of advanced cancer care and hence need comprehensive education in generalist palliative care competencies. These include symptom management, end-of-life care coordination, and communication or goals-of-care discussions. Notably, a recent national survey of radiation oncology residents indicated that most residents, 77% on average, perceived their educational training as suboptimal across domains of generalist palliative care competencies needed in oncology practice.22 Furthermore, a majority (81%) desired greater palliative care education within training.
The most common sites treated in this study were bone, brain, and lung sites. These data provide guidance to both education and research initiatives aiming to advance PRT curriculum and care structures within departments. For example, a same-day simulation and radiation treatment program developed at Princess Margaret Hospital Palliative Radiation Oncology Program (Ontario, Canada) aids in providing streamlined care for patients with bone metastases, the most common presentation for PRT.23 Furthermore, education and research in the application of PRT techniques to bone, brain, and thoracic disease cover the majority of PRT presentations. It is notable, however, that 17% were other soft tissue body sites.
