Background
Population-based cohort study using SEER-Medicare linkage. 18,698 patients with stage IV cancer who received palliative radiotherapy in the last 30 days of life. Evaluated trends in aggressive end-of-life (EOL) radiotherapy in the United States, and whether receipt of palliative RT in the last month of life reflects overtreatment or appropriate symptom management. Nguyen TK et al, JAMA Oncol 2019.
Interventions and follow up
Arm A: Palliative RT in last 30 days of life — rate, site, indication, fractionatio
Primary endpoint: Rate of palliative RT at end of life; trend analysi
mFollow up: N/A (cross-sectional/retrospective)
Primary endpoint: Rate of palliative RT at end of life; trend analysi
mFollow up: N/A (cross-sectional/retrospective)
Results
Comparison: Temporal trends 2000–2015; comparison to early palliative RT
Rate of RT in last 30 days of life: Declined from 7.6% (2000) to 5.7% (2015), P<.001
Single-fraction RT rate (EOL): Increased significantly over time (17% to 39%)
Hospice enrollment before EOL RT: Rare — most patients not enrolled in hospice
Radioresistant tumors: Higher rates of EOL RT (melanoma, RCC)
Rate of RT in last 30 days of life: Declined from 7.6% (2000) to 5.7% (2015), P<.001
Single-fraction RT rate (EOL): Increased significantly over time (17% to 39%)
Hospice enrollment before EOL RT: Rare — most patients not enrolled in hospice
Radioresistant tumors: Higher rates of EOL RT (melanoma, RCC)
Adverse events
Main adverse events: Late-course RT: travel burden, financial toxicity, time away from family/hospice. Fractionated RT requiring multiple visits in last weeks of life associated with poor quality of end-of-life care in oncology literature.
Conclusions
The rate of EOL palliative RT in the United States has declined over time with increasing use of single-fraction RT. This trend suggests improving alignment with palliative care goals. However, a subset of patients still receive fractionated RT in the last month of life without hospice enrollment, suggesting continued gaps in EOL care integration.
Key Limitations
Key Limitations: Administrative claims data — cannot determine whether EOL RT was appropriate for a given patient. SEER-Medicare limited to Medicare-insured ≥65 population. Cannot assess RT indication or symptom burden from claims data. Single-fraction trend improvement may overestimate quality improvement if patient selection is biased.
Clinical Context
EOL palliative RT utilization is a quality indicator in oncology. ASTRO guidelines recommend single-fraction RT for bone pain in patients with limited prognosis to minimize clinic visits. Advance care planning, hospice integration, and early PC referral (Temel 2010) are associated with reduced EOL aggressive treatment. Radiation oncologists should consider fractionation and timing with respect to prognosis and goals of care.
References