Estimating the Need for Palliative Radiation Therapy: A Benchmarking Approach

doi:10.1016/j.ijrobp.2015.09.045

International Journal of Radiation OncologyBiologyPhysics

Volume 94, Issue 1, 1 January 2016, Pages 51-59

https://doi.org/10.1016/j.ijrobp.2015.09.045 Get rights and content

Purpose

Palliative radiation therapy (PRT) benefits many patients with incurable cancer, but the overall need for PRT is unknown. Our primary objective was to estimate the appropriate rate of use of PRT in Ontario.

Methods and Materials

The Ontario Cancer Registry identified patients who died of cancer in Ontario between 2006 and 2010. Comprehensive RT records were linked to the registry. Multivariate analysis identified social and health system-related factors affecting the use of PRT, enabling us to define a benchmark population of patients with unimpeded access to PRT. The proportion of cases treated at any time (PRT_lifetime), the proportion of cases treated in the last 2 years of life (PRT_2y), and number of courses of PRT per thousand cancer deaths were measured in the benchmark population. These benchmarks were standardized to the characteristics of the overall population, and province-wide PRT rates were then compared to benchmarks.

Results

Cases diagnosed at hospitals with no RT on-site and residents of poorer communities and those who lived farther from an RT center, were significantly less likely than others to receive PRT. However, availability of RT at the diagnosing hospital was the dominant factor. Neither socioeconomic status nor distance from home to nearest RT center had a significant effect on the use of PRT in patients diagnosed at a hospital with RT facilities. The benchmark population therefore consisted of patients diagnosed at a hospital with RT facilities. The standardized benchmark for PRT_lifetime was 33.9%, and the corresponding province-wide rate was 28.5%. The standardized benchmark for PRT_2y was 32.4%, and the corresponding province-wide rate was 27.0%. The standardized benchmark for the number of courses of PRT per thousand cancer deaths was 652, and the corresponding province-wide rate was 542.

Conclusions

Approximately one-third of patients who die of cancer in Ontario need PRT, but many of them are never treated.

Introduction

Palliative radiation therapy (PRT) controls symptoms and improves quality of life in many patients with advanced cancer 1, 2, 3, 4, 5, 6. The rate of use of PRT in the general population varies widely, and the appropriate rate is unknown 7, 8, 9, 10. Achieving the achievable for patients with cancer requires that effective treatments should be accessible to every patient who needs them (11). It is therefore important to set standards for the appropriate use of PRT and to monitor adherence to those standards (11). The objectives of this study were to estimate the appropriate rate of use of PRT in Ontario and to audit compliance with this standard.

Two different methods have been used to estimate appropriate rates of use of RT (11). Evidence-based requirements analysis (EBEST) is a deductive modeling process 11, 12. Indications for RT are identified by systematic review of published reports, and the frequency of occurrence of each indication is estimated based on epidemiological information about case mix in the population of interest. This method has been used to estimate the need for RT in the initial management of cancer (12) and the lifetime need for RT 12, 13, 14. The validity of EBEST estimates depends on the quality of the multiple inputs required 12, 13, 14. The clinical evidence used to identify indications for RT is usually quite good, but the epidemiological evidence used to estimate the frequency of those indications is often weaker 11, 14. This is particularly true of PRT, because cancer registries do not compile the detailed information required to identify indications for PRT, except at the time of the initial diagnosis. EBEST has therefore been used to estimate the need for PRT in the initial management of cancer (15) but not to measure the lifetime need for PRT.

Criterion-based benchmarking (CBB) is an empirical method for estimating the appropriate rate of use of RT, which does not require detailed information about case mixture (16). CBB is based on the assumption that the rate of use of RT will be appropriate where there is optimal access to RT and where there is optimal decision-making about the use RT. The rate of use of RT observed in a benchmark population that meets those criteria provides an estimate of the appropriate rate (16). CBB is particularly useful in situations where there is insufficient epidemiological data to permit the use of EBEST (17). We therefore used the CBB method to estimate the lifetime need for PRT.

Section snippets

Ontario's radiation therapy system

Ontario's publically funded health system provides all medical and hospital care for its 14 million residents (18). All RT is provided by 14 government-funded cancer centers, which are coordinated by a provincial agency, Cancer Care Ontario. All radiation oncologists (ROs) work within multidisciplinary site groups at these centers and are paid through the province's publically funded health insurance program. There is no parallel private sector. Cancer Care Ontario creates and disseminates

Characteristics of the study population

In total, 185,348 patients with a history of cancer died between 2006 and 2010. We report the use of PRT only in the 127,547 patients whose death certificates recorded that they died of cancer. The remaining 57,801 patients whose death certificates recorded a cause of death other than cancer were not included in the analysis. Table 1 column 1 shows characteristics of the study population. Their median age was 74 and median survival was 10.7 months. The observed distribution of primary sites was

Discussion

Our main finding was that, in a benchmark Ontario population with unimpeded access to RT, 33.9% of patients received at least 1 course of PRT before their death from cancer. If this benchmark is correct, then we should conclude that approximately one-third of the people who die of cancer will need PRT at some point in the course of their illness. However, is this benchmark a valid estimate of the need for PRT? The explicit assumption underlying CBB is that the PRT rate will be optimal if there

Conclusions

To our knowledge, the benchmarks reported here are the first estimates of the lifetime need for PRT in the general cancer population. We do not claim that these benchmarks represent a precise measure of the need for PRT. However, we believe they may prove to be useful as conservative and demonstrably achievable targets for the use of PRT. The wide gap between actual rates and benchmarks indicates there is significant unmet need for PRT in Ontario. This represents an important opportunity to

Acknowledgments

The authors thank Cancer Care Ontario for providing access to the records used in this study.

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: The work was supported in part by team grant ADC-83510 from the Canadian Institute of Health Research (W.J.M.).

: Conflict of interest: none.

View full text

Clinical InvestigationEstimating the Need for Palliative Radiation Therapy: A Benchmarking Approach

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Ontario's radiation therapy system

Characteristics of the study population

Discussion

Conclusions

Acknowledgments

Pract Radiat Oncol

Int J Radiat Oncol Biol Phys

Cancer Treat Rev

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Clin Oncol

Clin Oncol

J Clin Epidemiol

Radiother Oncol

Clin Oncol

Palliative radiation therapy

JAMA

The principles of palliative radiotherapy: A radiation oncologist's perspective

Can J Oncol

Palliative radiotherapy for advanced malignancies in a changing oncologic landscape: Guiding principles and practice implementation

Ann Palliat Med

Factors affecting the use of palliative radiotherapy in Ontario

J Clin Oncol

Radiation therapy at the end of life: A population-based study examining palliative treatment intensity

Radiat Oncol

Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States

J Clin Oncol

Clinical Investigation
Estimating the Need for Palliative Radiation Therapy: A Benchmarking Approach