Patient-reported Symptom Burden, Rate of Completion of Palliative Radiotherapy and 30-day Mortality in Two Groups of Cancer Patients Managed With or Without Additional Care by a Multidisciplinary Palliative Care Team.

BACKGROUND/AIM: The aim of this study was to analyze differences in symptom burden, baseline and outcome parameters, including completion of palliative radiotherapy and 30-day mortality, between patients treated with palliative radiotherapy (RT) who were managed exclusively by regular oncology staff or a multidisciplinary palliative care team (MPCT) in addition. PATIENTS AND METHODS: This was a retrospective single-institution analysis. Comparison of two groups of patients: MPCT versus none (n=36 and 65, respectively). All patients provided Edmonton symptom assessment system (ESAS) data before RT. RESULTS: The MPCT group included significantly more patients with reduced performance status. Furthermore, these patients had higher ESAS symptom scores, except for two items (dyspnea, sleep). The largest differences were observed for pain, fatigue, anxiety and depression. The significant difference in pain scores was also reflected in different opioid medication rates. Failure to complete radiotherapy was more common in the MPCT group (11 and 2%, respectively, p=0.05). Thirty-day mortality was different, too (28 and 2%, respectively, p=0.0001). The Kaplan-Meier survival curves were not significantly different (1-year survival rates 21 and 25%, respectively, p=0.27). CONCLUSION: The MPCT group was characterized by a higher symptom burden. Prognostic factors such as performance status were not balanced between the two groups. Despite this fact, actuarial overall survival was comparable. Given the high rate of 30-day mortality in the MPCT group, efforts to optimize criteria for initiation of radiotherapy are warranted.

Does Patient-reported Dyspnea Reflect Thoracic Disease Characteristics in Patients with Incurable Cancer?

BACKGROUND/AIM: A considerable proportion of patients with incurable cancer experience dyspnea. This study evaluates associations between the feeling of dyspnea, as quantified by radiotherapy patients scoring their symptoms before palliative treatment with the Edmonton symptom assessment system (ESAS), and potential underlying causes. PATIENTS AND METHODS: Retrospective comparison of the incidence of different parameters that could cause a feeling of dyspnea in two groups, patients with no or minimal dyspnea (ESAS score 0-2) and those with dyspnea scores >2. RESULTS: The mean dyspnea score of all 102 patients was 2.6. Dyspnea scores >2 were present in 68% of patients with lung cancer, 50% of those with breast cancer, 39% of those with prostate cancer and 26% of those with other tumors (p=0.025). Dyspnea scores >2 were also present in 69% of patients with pleural effusion (vs. 40% in patients without pleural effusion), p=0.031. Among patients treated with palliative thoracic radiotherapy, 71% had dyspnea scores >2 (40% if other targets were irradiated), p=0.041. In 13% of patients, anemia and pulmonary comorbidity were the most likely explanation for dyspnea. In 29% the feeling of dyspnea could not be related to objective findings. CONCLUSION: In the majority of patients, the feeling of dyspnea was associated with the presence of thoracic metastases with or without pleural effusion from extrathoracic primary tumors or with a lung cancer diagnosis. A substantial proportion of patients reported dyspnea that could be related neither to cancer burden nor comorbidity.

Impact of early palliative interventions on the outcomes of care for patients with non-small cell lung cancer.

PURPOSE: The aim of this study is to address the question "does early palliative care in addition to standard oncology care or late additional palliative care improve patterns of terminal care in patients who died from non-small cell lung cancer (NSCLC)?" METHODS: We performed retrospective single-institution study of 286 patients. Palliative care was provided by a dedicated multidisciplinary palliative care team (PCT). An arbitrarily defined cutoff of 3 months before death was chosen to distinguish between early and late additional palliative care. Referral was at the discretion of the treating physicians who provided standard anticancer treatments. RESULTS: Patients who received early (8 %) or late (27 %) additional palliative care were significantly younger than those who did not receive additional palliative care. The likelihood of active anticancer treatment in the last month of life was lowest in the early additional palliative care group, p = 0.03. Patients who received early or late additional palliative care were significantly less likely to lack a documented resuscitation preference, p = 0.0001. Patients who received early additional palliative care were significantly less likely to become hospitalized in the last 3 months of life, p = 0.003. Place of death was also numerically different, with hospital death occurring in 33 % of patients who received early additional palliative care, as compared to 48 % in the late and 50 % in the no PCT group, p = 0.35. Anticancer treatment intensity was not reduced if the PCT contributed to the overall management. CONCLUSION: Early additional palliative care resulted in relevant improvements. The optimal timing of this intervention should be examined prospectively.

Palliative radiotherapy with or without additional care by a multidisciplinary palliative care team in patients with newly diagnosed cancer: a retrospective matched pairs comparison.

PURPOSE: To analyze survival after early palliative radiotherapy (RT) in patients managed exclusively by regular oncology staff or a multidisciplinary palliative care team (MPCT) in addition. METHODS: Retrospective matched pairs analysis. Comparison of two groups of 29 patients each: MPCT versus none. Early RT started within three months after cancer diagnosis. RESULTS: Bone and brain metastases were common RT targets. No significant differences in baseline characteristics were observed between both groups. Twelve patients in each group had non-small cell lung cancer. Median performance status was 2 in each group. Twenty-seven patients in each group had distant metastases. Median survival was not significantly different. In multivariate analysis, MPCT care was not associated with survival, while performance status and liver metastases were. Rate of radiotherapy during the last month of life was comparable. Only one patient in each group failed to complete radiotherapy. CONCLUSIONS: MPCT care was not associated with survival in these two matched groups of patients. The impact of MPCT care on other relevant endpoints such as symptom control, side effects and quality of life should be investigated prospectively.

Impact of comorbidity on survival after palliative radiotherapy.

PURPOSE: To evaluate prognostic factors for survival after palliative radiotherapy (PRT) with consideration of different comorbidities and the Charlson comorbidity index (CCI). PATIENTS AND METHODS: Between 2007 and 2012, 525 consecutive patients were treated with PRT and included in this retrospective study. Most patients received PRT for bone metastases, for brain metastases, or in order to improve thoracic symptoms from lung cancer. Median age was 69 years. Uni- and multivariate analyses were performed. RESULTS: Only 7% of patients had no comorbidity. A CCI of 1­2 was present in 49%, a CCI of 3­4, in 36%, and a higher CCI in 9% of patients. Younger patients, female patients, and patients who had not been smokers had significantly less comorbidity. Patients without comorbidity had significantly better median performance status (PS) and were more likely to receive palliative systemic therapy. Both lower CCI and absence of more than one cancer diagnosis independently predicted longer survival. Further significant parameters in multivariate analysis were PS and number of organs with metastatic involvement. Exploratory analyses suggested that the impact of CCI was largest in patients older than 60 years and was absent in those with brain metastases. CONCLUSION: We recommend assessment of comorbidity when prescribing PRT and selecting the optimal fractionation regimen, because most patients with severe comorbidities had limited survival. One of the possible explanations could be that only a minority of these patients are fit for systemic therapy, which plays an important role in the overall treatment concept.

Palliative Radiotherapy with or without Additional Care by a Multidisciplinary Palliative Care Team: A Retrospective Comparison.

Purpose. To analyze pattern of care and survival after palliative radiotherapy (RT) in patients managed exclusively by regular oncology staff or a multidisciplinary palliative care team (MPCT) in addition. Methods. Retrospective analysis of 522 RT courses. Comparison of Two Groups: MPCT versus none. Results. We analyzed 140 RT courses (27%) with MPCT care and 382 without it. The following statistically significant differences were observed: 33% of female patients had MPCT care versus only 23% of male patients and 37% of patients <65 years had MPCT care versus only 22% of older patients. MPCT patients were more likely to have poor performance status and liver metastases. In the MPCT group steroid and opioid use was significantly more common. Dose-fractionation regimens were similar. Median survival was significantly shorter in the MPCT group, 3.9 versus 6.9 months. In multivariate analysis, MPCT care was not associated with survival. Adjusted for confounders, MPCT care reduced the likelihood of incomplete RT by 33%, P > 0.05. Conclusions. Patterns of referral and care differed, for example, regarding age and medication use. It seems possible that MPCT care reduces likelihood of incomplete RT. Therefore, the impact of MPCT care on symptom control should be investigated and objective referral criteria should be developed.

Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.

The present study aimed to develop a predictive model that would allow for reduced utilization of palliative radiotherapy (PRT) during the final 30 days of life in patients with incurable cancer. We performed uni- and multivariate analyses of factors predicting PRT during the final 30 days of life for all PRT courses administered at a dedicated PRT facility between 20.06.2007 and 31.12.2009. We also developed a predictive model by recursive partitioning analysis (RPA), followed by independent validation of its performance in patients treated during 2010 and 2011. We analyzed 579 PRT courses. Median survival was 6.3 months. In 53 cases (9%) PRT was administered during the final 30 days of life. RPA resulted in a model consisting of six parameters (lung or bladder cancer, Eastern Cooperative Oncology Group performance status of 3-4, low hemoglobin, opioid analgesic use, steroid use, known progressive disease outside PRT volume), which correctly identified 75% of PRT courses administered during the final 30 days of life. Maximum survival of patients fulfilling all criteria was 69 days. Death within 40 days occurred in 83% of patients. In the independent validation data set, similar results were obtained: 74% (30 days), 84% (40 days), while maximum survival was 92 days. As demonstrated here and in other recent studies, assigning the right patient to the right palliative approach is challenging. We suggest that patients with lung or bladder cancer and the adverse features mentioned above are at high risk of dying shortly after initiation of PRT. Our model might support decision-making (best supportive care versus PRT) and is the first decision aid specifically addressing PRT near end of life.

Best supportive care in patients with brain metastases and adverse prognostic factors: development of improved decision aids.

PURPOSE: This study aimed to develop a survival prediction model that might aid decision making when choosing between best supportive care (BSC) and brain radiotherapy (RT) for patients with brain metastases and limited survival expectation. METHODS: A retrospective analysis of 124 patients treated with BSC, whole brain radiotherapy (WBRT), or radiosurgery was conducted. All patients had adverse prognostic features defined as 0-1.5 points according to the diagnosis-specific graded prognostic assessment score (DS-GPA) or GPA if primary tumor type was not among those represented in DS-GPA. Kaplan-Meier survival curves were compared between patients treated with BSC or RT in different scenarios, reflecting more or less rigorous definitions of poor prognosis. If survival was indistinguishable and this result could be confirmed in multivariate analysis, BSC was considered appropriate. RESULTS: Irrespective of point sum examined, DS-GPA by itself was not a satisfactory selection parameter. However, we defined a subgroup of 63 patients (51 %) with short survival irrespective of management approach (only 5 % of irradiated patients survived beyond 6 months; they had newly diagnosed, treatment-naïve lung cancer), i.e., patients in whom foregoing RT was unlikely to compromise survival. These were patients with 0-1.5 points and aged ≥ 75 years, had Karnofsky performance status ≤ 50, or had uncontrolled primary tumor with extracranial metastases to at least two organs. CONCLUSIONS: BSC is a reasonable choice in patients with limited life expectancy. After successful external validation of the selection criteria developed in this analysis, identification of patients who are unlikely to benefit from WBRT might be improved.