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Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases.

ABSTRACT: Background:Best-practice guidelines recommend single-fraction (SFRT) instead of multi-fraction radiation therapy (MFRT) for uncomplicated symptomatic bone metastases. SFRT is comparable to MFRT in relieving pain, convenient for patients, and cost-effective. Patterns of practice in Canada reveal that SFRT is underused, with significant variability across the country. We audited SFRT use and studied factors that may influence treatment decisions at a large academic tertiary care center in Quebec, Canada. Methods:Patients who received radiotherapy for uncomplicated bone metastases between February 2014 and March 2015 were reviewed. Age, gender, primary histology, site of metastases and performance status were identified as potential factors affecting fractionation. These were explored by Fisher's test on univariate analysis and logistic regression for multivariate analysis. Retreatment rates were analyzed with cumulative incidence and compared with Gray's test. Results:254 radiotherapy courses were administered to 165 patients, 85.4% of which were delivered using a single fraction of 8?Gy. Patients age less than 70?years and those with breast histology were more likely to receive MFRT (p?=?0.04; p?=?0.0046). Performance status (ECOG) was a significant predictor of fractionation because of high correlations between young age, breast histology, and ECOG status (p?=?0.03). Follow-up was too short in 40% of patients to derive definitive conclusions on retreatment. Conclusions:In accordance with current guidelines, our audit confirms that use of SFRT in patients with uncomplicated bone metastases at our center is high. We identified that patient age, primary histology, and performance status influenced fractionation. Incorporation of this quality indicator into our performance dashboard will allow assessment of retreatment differences and other criteria that may also influence treatment choice.

SUBMITTER: Di Lalla V

PROVIDER: S-EPMC7033799 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases.

Di Lalla Vanessa V Fortin Bernard B Pembroke Catherine C Freeman Carolyn C Yassa Michael M Hijal Tarek T

Technical innovations & patient support in radiation oncology 20190117

<h4>Background</h4>Best-practice guidelines recommend single-fraction (SFRT) instead of multi-fraction radiation therapy (MFRT) for uncomplicated symptomatic bone metastases. SFRT is comparable to MFRT in relieving pain, convenient for patients, and cost-effective. Patterns of practice in Canada reveal that SFRT is underused, with significant variability across the country. We audited SFRT use and studied factors that may influence treatment decisions at a large academic tertiary care center in ...[more]

PMID: 32095590

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Project description:Background: There is an increasing need for evidence-based efficiency in providing a growing amount of cancer care. One example of a quality gap is the use of multiple-fraction palliative radiation for patients with advanced cancer who have uncomplicated bone metastases; evidence suggests similar pain outcomes for treatment regimens with a lower burden of treatments. Methods: During the first phase of quality improvement work, we used RAND/UCLA appropriateness methodology to understand how radiation oncologists at one academic medical center rate the appropriateness of different treatment regimens for painful uncomplicated bone metastases. We compared radiation oncologist appropriateness ratings for radiation treatments with radiation therapy provided by these oncologists to patients with painful bone metastases between July 2012 and June 2013. Results: Appropriateness ratings showed that single-fraction (8 Gy) treatment (a low burden treatment) was consistently considered an appropriate option to treat a variety of uncomplicated bone metastases. The use of >10 fractions was consistently rated as inappropriate regardless of other factors. Eighty-one patients receiving radiation therapy for painful bone metastases during the study period had an available medical record for chart abstraction. Almost one-third of metastases were considered complicated because of a concern of spinal cord compression, a history of prior irradiation, or an associated pathological fracture. Among uncomplicated bone metastases, 25% were treated with stereotactic body radiation treatment (SBRT). Among the 54 uncomplicated bone metastases treated with conformal radiation, only one was treated with single-fraction treatment and 32% were treated with greater than 10 fractions. Conclusions: Treatment at the study site demonstrates room for improvement in providing low-burden radiation oncology treatments for patients with painful bone metastases. Choosing a radiation treatment schedule for patients with advanced cancer and painful bone metastases requires consideration of many medical and patient-centered factors. Our experience suggests that it will take more than the existence of guidelines to change practice in this area.

Project description:PurposeTo assess US radiation oncologists' views on practice scope and the ideal role of the radiation oncologist (RO), the American Society for Radiation Oncology (ASTRO) conducted a scope of practice survey.Methods and materialsIn spring 2019, ASTRO distributed an online survey to 3822 US RO members. The survey generated 984 complete responses (26% response rate) for analysis. Face validity testing confirmed respondents were representative of ASTRO's RO membership.ResultsNearly all respondents agreed that "ROs should be leaders in oncologic care." Respondents indicated the ideal approach to patient care was to provide "an independent opinion on radiation therapy and other treatment options" (82.5%) or "an independent opinion on radiation therapy but not outside of it" (16.1%), with only 1.4% favoring provision of "radiation therapy at the request of the referring physician" as the ideal approach. Actual practice fully matched the ideal approach in 18.2% of respondents. For the remaining majority, actual practice did not always match the ideal and comprised a mix of approaches that included providing radiation at the referring physician's request 24.0% of the time on average. Reasons for the mismatch included fear of alienating referring physicians and concern for offering an unwelcome opinion. One-fifth of respondents expressed a desire to expand the scope of service though interspecialty politics and insufficient training were potential barriers. Respondents interested in expanding scope of practice were on average earlier in their career (average years in practice 13.3) than those who were not interested (average years in practice 17.2, P < .001). Radiopharmaceuticals administration, medical marijuana and anticancer medications prescribing, and RO inpatient service represented areas of interest for expansion but also knowledge gaps.ConclusionsThese results provide insight regarding US ROs' scope of practice and attitudes on the ideal role of the RO. For most ROs, to provide an independent opinion on treatment options represented the ideal approach to care, but barriers such as concern of alienating referring physicians prevented many from fully adhering to their ideal in practice. Actual practice commonly comprised a mixed approach, including the least favored scenario of delivering radiation at the referring physician's request one-quarter of the time, highlighting the influence of interspecialty politics on practice behavior. Advocacy for open communication and meaningful interdisciplinary collaboration presents an actionable solution toward a more balanced relationship with other specialties as ROs strive to better fulfill the vision of being leaders in oncologic care and being our best for our patients. The study also identified interest in expanding into nontraditional domains that offer opportunities to address unmet needs in the cancer patient's journey and elevate radiation oncology within the increasingly value-based US health care system.

Project description:OBJECTIVE Although postoperative stereotactic body radiation therapy (SBRT) for spinal metastases is increasingly performed, few guidelines exist for this application. The purpose of this study is to develop consensus guidelines to promote safe and effective treatment for patients with spinal metastases. METHODS Fifteen radiation oncologists and 5 neurosurgeons, representing 19 centers in 4 countries and having a collective experience of more than 1300 postoperative spine SBRT cases, completed a 19-question survey about postoperative spine SBRT practice. Responses were defined as follows: 1) consensus: selected by ≥ 75% of respondents; 2) predominant: selected by 50% of respondents or more; and 3) controversial: no single response selected by a majority of respondents. RESULTS Consensus treatment indications included: radioresistant primary, 1-2 levels of adjacent disease, and previous radiation therapy. Contraindications included: involvement of more than 3 contiguous vertebral bodies, ASIA Grade A status (complete spinal cord injury without preservation of motor or sensory function), and postoperative Bilsky Grade 3 residual (cord compression without any CSF around the cord). For treatment planning, co-registration of the preoperative MRI and postoperative T1-weighted MRI (with or without gadolinium) and delineation of the cord on the T2-weighted MRI (and/or CT myelogram in cases of significant hardware artifact) were predominant. Consensus GTV (gross tumor volume) was the postoperative residual tumor based on MRI. Predominant CTV (clinical tumor volume) practice was to include the postoperative bed defined as the entire extent of preoperative tumor, the relevant anatomical compartment and any residual disease. Consensus was achieved with respect to not including the surgical hardware and incision in the CTV. PTV (planning tumor volume) expansion was controversial, ranging from 0 to 2 mm. The spinal cord avoidance structure was predominantly the true cord. Circumferential treatment of the epidural space and margin for paraspinal extension was controversial. Prescription doses and spinal cord tolerances based on clinical scenario, neurological compromise, and prior overlapping treatments were controversial, but reasonable ranges are presented. Fifty percent of those surveyed practiced an integrated boost to areas of residual tumor and density override for hardware within the beam path. Acceptable PTV coverage was controversial, but consensus was achieved with respect to compromising coverage to meet cord constraint and fractionation to improve coverage while meeting cord constraint. CONCLUSIONS The consensus by spinal radiosurgery experts suggests that postoperative SBRT is indicated for radioresistant primary lesions, disease confined to 1-2 vertebral levels, and/or prior overlapping radiotherapy. The GTV is the postoperative residual tumor, and the CTV is the postoperative bed defined as the entire extent of preoperative tumor and anatomical compartment plus residual disease. Hardware and scar do not need to be included in CTV. While predominant agreement was reached about treatment planning and definition of organs at risk, future investigation will be critical in better understanding areas of controversy, including whether circumferential treatment of the epidural space is necessary, management of paraspinal extension, and the optimal dose fractionation schedules.

Project description:To examine characteristics of medical malpractice claims involving radiation oncologists closed during a 10-year period.Malpractice claims filed against radiation oncologists from 2003 to 2012 collected by a nationwide liability insurance trade association were analyzed. Outcomes included the nature of claims and indemnity payments, including associated presenting diagnoses, procedures, alleged medical errors, and injury severity. We compared the likelihood of a claim resulting in payment in relation to injury severity categories (death as referent) using binomial logistic regression.There were 362 closed claims involving radiation oncology, 102 (28%) of which were paid, resulting in $38 million in indemnity payments. The most common alleged errors included "improper performance" (38% of closed claims, 18% were paid; 29% [$11 million] of total indemnity), "errors in diagnosis" (25% of closed claims, 46% were paid; 44% [$17 million] of total indemnity), and "no medical misadventure" (14% of closed claims, 8% were paid; less than 1% [$148,000] of total indemnity). Another physician was named in 32% of claims, and consent issues/breach of contract were cited in 18%. Claims for injury resulting in death represented 39% of closed claims and 25% of total indemnity. "Improper performance" was the primary alleged error associated with injury resulting in death. Compared with claims involving death, major temporary injury (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.29-5.85, P=.009), significant permanent injury (OR 3.1, 95% CI 1.48-6.46, P=.003), and major permanent injury (OR 5.5, 95% CI 1.89-16.15, P=.002) had a higher likelihood of a claim resulting in indemnity payment.Improper performance was the most common alleged malpractice error. Claims involving significant or major injury were more likely to be paid than those involving death. Insights into the nature of liability claims against radiation oncologists may help direct efforts to improve quality of care and minimize the risk of being sued.

Dataset Information

Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases.

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Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases.

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