9/19/2017. Palliative Radiotherapy We Can Actually Afford: A New Program Designed to Help Patients and Caregivers Save Resources

Transcription

1 Palliative Radiotherapy We Can Actually Afford: A New Program Designed to Help Patients and Caregivers Save Resources Christopher Abraham, MD Assistant Professor Department of Radiation Oncology Washington University School of Medicine Patrick White, MD, HMDC, FACP, FAAHPM Chief Medical Officer, BJC Home Care Assistant Professor of Medicine Washington University School of Medicine 1 Disclosure: There are no relevant financial relationships to disclose regarding this presentation Patrick White, MD Chris Abraham, MD 2 Objectives 1) Describe 3 potential benefits of palliative radiation 2) Identify 3 obstacles to the use of palliative radiation in the hospice setting 3) Describe how a new program can make palliative radiation available to all hospice patients 3 1

2 My Background Internal Medicine- Washington University/BJH PhD Program, Clinical and Translational Science, University of Pittsburgh Co-Chief Medical Officer, University of Pittsburgh s Hospice Program Chief Medical Officer, BJC Home Care My Background MD, Saint Louis University Radiation Oncology Residency, Barnes- Jewish Hospital Assistant Professor, Department of Radiation Oncology Washington University in St. Louis 5 States Worse Than Death Among Hospitalized Patients With Serious Illnesses Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med PMID

3 Radiotherapy Basics Radiotherapy utilizes high energy radiation to damage DNA X-rays, gamma rays, charged particles DNA damage is not specific to cancer cells alone Radiotherapy may be delivered locally or systemically Local radiotherapy may be delivered externally or internally Radiation dose is prescribed in Gray and fractions Fractionation is utilized to: Minimize normal tissue toxicity Increase the likelihood DNA damage Radiotherapy Basics Radiotherapy may be given with definitive OR palliative intent Nearly 50% of all radiotherapy is given with palliative intent Radiotherapy prescription dichotomy: Local control IS impacted by dose Locally advanced lung cancer: 60Gy/30 fractions Palliative effect IS NOT impacted by dose Bone metastasis: 8Gy/1 fraction Historical Perspective When the initial objective of radiation therapy is palliation, new ground rules must be applied. Possible serious complications or even slowly self-limiting side effects of treatment are no longer acceptable. Overall treatment time must be short. Cost must be minimized. Convenience of treatment must be considered. - JAMA,

4 Palliative Radiotherapy Palliative radiotherapy: Effective at improving symptoms Pain Dysphagia / odynophagia Bleeding Obstruction Improves quality of life Safe with limited side effects Time-efficient Cost-effective Convenient Palliative Radiotherapy Indications Primary Sites of Disease Brain headaches, neurologic dysfunction Head and neck pain, bleeding, dysphagia, SOB Lung pain, hemoptysis, SVC, post-obstructive PNA GU pain, hematuria, obstruction GI pain, bleeding, tenesmus, obstruction Secondary Sites of Disease Bone pain, cord compression Skin, subcutaneous tissues Spleen pain, early satiety Overlap with primary sites of disease Palliative Radiotherapy Exclusions Patient Imminent death Inability to provide consent Multiple progressive systems Treatment Side effects > risks Unsafe Health Care System Cost Transportation 4

5 Site Specific Treatment Bone Metastases 14 Bone Metastasis Palliative Radiotherapy Trials for Bone Metastasis: A Systematic Review Chow, JCO 2007 Meta-analysis including 16 randomized trials >5000 patients in total Randomized between single fraction vs. multiple fractions 8Gy / 1 fraction vs 20Gy/5, 30Gy/10, etc Multiple pathologic types included Multiple outcomes assessed: Overall response Complete response Re-treatment 5

6 Bone Metastasis Overall response Single fraction: 58%, Multi fraction: 59% Bone Metastasis Complete response Single fraction: 23%, Multi fraction: 24% Bone Metastasis Re-treatment Single fraction: 20%, Multi fraction: 8% 6

7 Bone Metastasis: Re-treatment Single versus multiple fractions of repeat radiation for painful bone metastasis: a randomized controlled, noninferiority trial Chow, Lancet Onc 2014 RCT of 8Gy / 1fx vs. 20Gy / 5 fx RT for re-treatment No difference in overall pain response Acute radiation related toxicities higher in multi-fraction No difference in cord compression or pathologic fracture Bone Metastasis: End of Life Efficacy of radiotherapy for painful bone metastases during the last 12 weeks of life: results from Dutch Bone Metastasis Study Meeuse, CA 2010 RTC of single vs multi fraction radiotherapy Cohort of patients who died within 12 weeks after randomization Results Pain response 45% overall Median time to relief 2 weeks 7

8 Bone Metastasis Conclusions For bone metastasis: Radiotherapy is effective at improving pain Single fraction is equivalent to multi fraction: Overall response Complete response Re-treatment rates are 2.5 times with single fraction radiotherapy When re-treatment: Re-treatment is effective at improving pain Single fraction is equivalent to multi fraction Palliative radiotherapy is effective at the end of life Spinal Cord Compression Spinal Cord Compression 8Gy single dose radiotherapy is effective in metastatic spinal cord compression: Results of a phase III randomized multicenter Italian trial Maranzano, Rad Onc 2009 RCT of 8Gy / 1 fraction vs 8Gy / 2 fractions for MSCC Patients with short life expectancy No difference in response Pain Motor and sphincter function No difference in duration of response 8

9 Other sites Thoracic Palliative Thoracic Radiotherapy for Lung Cancer: A Systematic Review Fairchild, JCO 2007 Meta-analysis including 13 randomized trials >3000 patients Randomized patients to short or long course Multiple outcomes assessed Symptom palliation Survival Toxicity Re-irradiation rate Thoracic (Hemoptysis) 9

10 Thoracic (Cough) Thoracic (Chest Pain) Esophageal Stricture Single-dose brachytherapy verus metal stent placement for palliation of dysphagia from oesophageal cancer: multicenter randomized trial Homs, Lancet 2004 Prospective randomized trial Randomized between stent and brachytherapy >200 patients Results: Stent more rapid relief Brachy more long relief, improved QOL Brachy fewer complications 10

11 Large Pelvic Masses Phase II study of multiple daily fractionations in palliation of advanced pelvic malignancies: preliminary report of RTOG 8502 Spanos, IJROBP pts with advanced pelvic malignancies Gyn, colorectal, GU, misc 3.7Gy BID x 2 days, 3-6 weeks off, repeat x2 Total of 44.4Gy After completion of 3 courses: CR 15% PR 32% Stable - 35% Conclusions Palliative radiotherapy is: Effective Safe Time efficient Radiotherapy is useful for: Primary and secondary disease Multiple anatomic sites Single fraction radiation is often reasonable and appropriate means for palliation Barriers to Radiation Therapy in Hospice Care Perception Hospice Provider s Perception Radiation Oncologists Perception Barriers Educational Barriers Economic Barriers Research Barriers Outcome Less than 3% of hospice patients receive radiation therapy Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Onc. 2014; 32(26):

12 Barriers to Radiation Therapy in Hospice Care: Survey of Hospice Providers (Easy Questions) Question % Yes 1) Is radiation therapy (RT) important in palliative care? 87% 2) Do you feel sufficiently trained for when to use RT? 52% 3) Is RT available to your patients? 74% 4) Do you have access to a radiation oncologist to discuss your patients? 75% 5) Would you be willing to attend palliative RT lectures? 94% Lutz S, Spence C, Chowe E, Janjan N, Connor S. Survey on use of palliative radiotherapy in hospice care. J Clin Oncol. 2004; 22(17): Barriers to Radiation Therapy in Hospice Care: Survey of Hospice Providers (Hard Questions) Question 1) Do you feel radiation oncologists are sufficiently trained in palliative care to render opinions regarding treatment of hospice cancer patients? 2) Are radiation oncologists resistant to prescribing single-fraction treatments? 3) Would you be willing to recruit hospice patients into trials measuring the worth of palliative radiotherapy in certain circumstances? % Yes 56% 76% 59% 35 Educational Barriers Lack of formal palliative care training for radiation oncology residents Lack of radiotherapy training for palliative care professionals Minimal protected time at national meetings for palliative oncology topics Lack of training for hospice clinicians in identifying situations where radiation therapy may improve QOL Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Onc. 2014; 32(26):

13 Economic Barriers Economic incentives to prescribe protracted courses of radiation therapy Radiotherapy costs several times the average hospice per diem Transportation costs are often borne by hospice organizations and may even be more expensive than the radiotherapy itself Caregivers may not be able to take the time off work to complete protracted course of radiation therapy Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Onc. 2014; 32(26): Economic Impact of Single-fraction Versus Multi-fraction Radiotherapy 38 International Variation in Practice Patterns Comparing Single-Fraction to Multi-fraction Radiotherapy 39 13

14 Research Barriers Paucity of experienced research teams in hospice and palliative care programs Missing data points because of declining health or death of accrued patients Lack of federal funds dedicated to end-of-life studies Paucity of clinical trials comparing different radiation regimens for many conditions (outside of painful bone metastases) Lutz ST, Jones J. Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Onc. 2014; 32(26): Improving Access to Radiotherapy More focused collaborations between radiation oncologists and hospice/palliative care physicians Emphasis on hypofractionated courses for patients with poor prognoses Formalized training for both radiation oncology residents and palliative care fellows on the nuances of palliative radiotherapy Formation of more radiotherapy overuse guidelines and quality measures and increased accountability 41 Hospice / Palliative Logistics for New Palliative Radiotherapy Clinic at CHNE 14

15 New Palliative Radiation Oncology Clinic Who- Any hospice patient with painful bone metastases or spinal cord compression regardless of hospice provider What-Palliative radiation clinic specializing in single fraction radiotherapy Where-Christian Hospital Northeast in Saint Louis When-Now! Why-Need for inexpensive, single fraction radiation therapy to help improve quality of life while reducing the burdens on patients and caregivers 43 What Makes This Radiotherapy Practical Reduced Professional Fee-Washington University Radiation Oncology has agreed to bill only a ($290.52) which is a level 3 visit with low complexity Christian Hospital will allow a single fraction without a CT simulation or additional imaging to keep costs ($328.13) minimal. Total costs for the technical fee and professional fee and imaging will be $ (adjusted for Medicare Fee Schedule) and the entire process will typically be conducted in one visit! This could result in reduced ambulance costs, lower caregiver burden, decreased transportation discomfort, longer hospice LOS, etc. 44 Information Needed From the Referring Hospice Is the patient able to lie flat? (okay if not but need to know) Is the patient able to follow instructions, can the safely be placed on a treatment table? Is the patient decisional to sign consent for treatment? if not POA must be present for consult and treatment to give consent

16 Logistics Hospice determines radiotherapy need Radiation Oncology assessment Case discussed with Radiation Oncology Transportation Simulation Formal referral rendered Pre-medication Quality Assurance Continued assessment of need Delivery of single fraction radiotherapy References Conway JL, Yurkowski E, Glazier J, et al. Comparison of Patient-reported Outcomes with a Single Versus Multiple Fraction Palliative Radiotherapy for Bone Metastasis in a Population-based Cohort. Radiother Oncol. 2016; 119(2): Chow E, van der Linden YM, Roos D, et al. Lancet Oncol. Single Versus Multiple Fractions of Repeat Radiation for Painful Bone Metastases: a Randomized, Controlled, Non-inferiority Trial Feb;15(2): Collinson L, Kvizhinadze G, Nair N, McLeod M, Blakely T. Economic Evaluation of Single-fraction Versus Multiple-fraction Palliative Radiotherapy for Painful Bone Metastases in Breast, Lung and Prostate Cancer. J Med Imaging Radiat Oncol. 2016; 60(5): Chow E, Hahn CA, Lutz ST, Global Reluctance to Practice Evidence-based Medicine Continues in the Treatment of Uncomplicated Painful Bone Metastases Despite Level 1 Evidence and Practice Guidelines. Int J Radiat Oncol Bio Phys. 2012;83(1):e Saito T, Toya R, Semba A, et al. Influence of the Treatment Schedule on the Physicians' Decisions to Refer Bone Metastases Patients for Palliative Radiotherapy: a Questionnaire Survey of Physicians in Various Specialties. Nagoya J Med Sci. 2016; 78(3): Fairchild A, Barnes E, Ghosh S, et al. International Patterns of Practice in Palliative Radiotherapy for Painful Bone Metastases: Evidence-based Practices? Int. J. Radiation Oncology Biol. Phys. 2009;75(5): Thavarajah N, Zhang L, Wong K, Bedard G. Patterns of Practice in the Prescription of Palliative Radiotherapy for the Treatment of Bone Metastases at the Rapid Response Radiotherapy Program Between 2005 and Curr Oncol Oct;20(5):e References (continued) McDonald R, Ding K, Brundage M, et al. Effect of Radiotherapy on Painful Bone Metastases: A Secondary Analysis of the NCIC Clinical Trials Group Symptom Control Trial SC.23. JAMA Oncol Epub ahead of print. Howell DD, James JL, Hartsell WF, Suntharalingam M. Single-fraction Radiotherapy Versus Multifraction Radiotherapy for Palliation of Painful Vertebral Bone Metastases-equivalent Efficacy, Less Toxicity, More Convenient: a Subset Analysis of Radiation Therapy Oncology Group trial Cancer. 2013; 119(4): Moghanaki D, Cheuk AV, Fosmire H, Anscher MS. Availability of Single-fraction Palliative Radiotherapy for Cancer Patients Receiving End-of-life Care Within the Veterans Healthcare Administration. J Palliat Med. 2014;17(11): Lutz ST, Jones J, Chow E. Role of Radiation Therapy in Palliative Care of the Patient with Cancer. J Clin Oncol. 2014; 32(26):2913 Lutz S, Spence C, Chow E, Janjan N, Connor S. Survey on Use of Palliative Radiotherapy in Hospice Care. J Clin Oncol. 2004; 22(17): McCloskey SA, Tao ML, Rose CM, Fink A, Amadeo AM. National Survey of Perspectives of Palliative Radiation Therapy: Role, Barriers, and Needs. Cancer J. 2007; 13(2):