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Journal of Clinical Oncology, Vol 22, No 17 (September 1), 2004: pp. 3581-3586 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.11.151 Survey on Use of Palliative Radiotherapy in Hospice CareFrom the Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH; National Hospice and Palliative Care Organization, Alexandria, VA; Department of Radiation Oncology, Toronto Regional Sunnybrook Cancer Center, Toronto, Ontario, Canada; and the Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX Address reprint requests to Stephen T. Lutz, MD, MS, Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, 15990 Medical Dr, Findlay, OH 45840; e-mail: slutz{at}bvha.org
PURPOSE: Radiation oncologists and hospice professionals both provide end-of-life care for oncology patients, and little has been written about the interface between these two groups of specialists. Hospice professionals were surveyed to assess the perceived need for palliative radiotherapy in the hospice setting, to investigate factors that limit the access of hospice patients to radiotherapy, and to suggest areas of future collaboration on education, research, and patient advocacy. PATIENTS AND METHODS: Members of the National Hospice and Palliative Care Organization (NHPCO) and American Society for Therapeutic Radiology and Oncology jointly authored a questionnaire to investigate the beliefs of hospice professionals toward the use of radiotherapy for oncology patients in hospice. The questionnaire was distributed to all NHPCO member institutions, and the results were compiled and statistically analyzed. RESULTS: Four hundred eighty of more than 1,800 surveyed facilities responded to the questionnaire. The findings suggest that the majority of hospice professionals feel that radiotherapy is important in palliative oncology and that radiotherapy is widely available in the United States. Yet less than 3% on average of hospice patients served by hospices responding to the survey actually received radiotherapy in 2002. The most common barriers to radiotherapy in hospice care include radiotherapy expense, transportation difficulties, short life expectancy, and educational deficiencies between the specialties. CONCLUSION: Multiple barriers act to limit the use of palliative radiotherapy in hospice care. Finding ways to surmount these obstacles will provide opportunity for improvement in the end-of-life care of cancer patients.
The major goal of hospice care is to provide palliation for patients whose life expectancy is 6 months or less if the illness runs its normal course. An increasing number of patients are admitted to hospice for end-of-life management of cancer, representing 51% of admissions in 2002.1,2 Cancer patients may require intensive intervention to alleviate multifactorial symptoms, and hospice professionals must find a means by which to provide sufficient palliative care for cancer patients, despite referrals that occur very late in the disease course. Data from 2002 suggest that the length of stay for cancer patients admitted to hospice averages 51 days, with a median of 21 days.2 Within this interval, the hospice provider must assess symptoms and provide care within the constraints of a Medicare reimbursement system that limits per diem monetary reimbursement to an average of $114 for routine home care. This financial constraint limits the ability of most hospice programs to offer relatively expensive interventions that may drain resources from the care of other patients and jeopardize the financial viability of the program. Still, few studies have assessed the need for those other interventions in the hospice setting. One study did find an association between greater total-patient days and the potential availability of radiotherapy and chemotherapy, suggesting that larger hospices might more easily absorb the costlier treatments by distributing the financial burden over a larger total population of patients. Seventy-one percent of the hospices in that same survey reported availability of radiotherapy services, and that availability did not differ between for-profit and not-for-profit programs.3 Radiotherapy provides excellent palliative relief in a wide range of oncologic situations. Most radiation oncology departments report that 40% to 50% of referrals are sent for the palliative treatment of malignancy.4,5 The need for palliative radiotherapy in lung cancer patients may be inferred from a randomized trial completed in England on patients who had completed their initial anticancer treatment and were expected to survive 3 months. Four percent of those patients required radiotherapy in the 3 months after placement in the study, though the utilization rate of radiotherapy rose to 17% in that group of patients who were randomly assigned to receive conventional follow-up plus intensive monthly follow-up by clinical nurse specialists.6 The financial cost of radiotherapy, however, places it in the category of those interventions whose expense exceeds the daily hospice per diem. Thus the current system of reimbursement tends to polarize the disease management of palliative oncology patients into phases of care. There are several publications that describe the worth of short-course palliative radiotherapy for common clinical situations, but, to our knowledge, there have been no trials to assess the usefulness of radiotherapy on symptom management or quality of life in patients who have been admitted to hospice.7-17 Although radiation oncologists and hospice professionals overlap a great deal in the types of patients for whom they provide care, there has been little effort to this time to collaborate in both research and education to advance care in this group of fragile patients. The current study used a questionnaire to investigate the beliefs of hospice professionals toward the use of radiotherapy for patients who have been admitted to hospice with the diagnosis of cancer. Our goals were to assess the perceived need for palliative radiotherapy in the hospice setting, to investigate factors that limit the access of hospice patients to palliative radiotherapy, and to suggest potential areas of future collaboration between the two specialties, especially as related to education, research, and patient advocacy.
A cover letter and 19-item questionnaire were formulated to directly question hospice professionals about their opinions regarding palliative radiotherapy for cancer patients cared for in the hospice setting (Appendices 1 and 2). The contents of the survey were determined jointly by palliative care researchers in both the American Society for Therapeutic Radiology and Oncology (ASTRO) and the National Hospice and Palliative Care Organization (NHPCO). The NHPCO is the largest national association of hospices, with a membership of 2,400 individual hospices affiliated with 1,800 distinct companies that are estimated to serve more than 80% of all hospice patients nationally. The questionnaire was distributed to each hospice with an active 2002 membership in NHPCO. A decision was made to allow each hospice to determine which member of the hospice professional team would answer the questionnaire, despite the obvious difference between the role—and possibly depth of knowledge related to palliative radiotherapy—of the physician, nonphysician clinician, and administrator in any given program. This choice was made to both maximize the rate of response as well as to permit some investigation of the difference in attitudes between each of these members of the hospice team. The questionnaire was distributed by facsimile, and the respondents were given the choice to respond by facsimile, standard mail, or online through the NHPCO internet site. The NHPCO routinely uses questionnaires to survey its members about palliative care issues, so the potential respondents were familiar with the survey format and methods of response.
Univariate and bivariate statistical analyses using summary statistics, frequency procedures, and cross-tabulation were performed to determine characteristics of the participating hospices and to describe the respondents' attitudes toward palliative radiotherapy. The data were further evaluated to determine whether the respondents differed in their attitude toward palliative radiotherapy based on their professional role and responsibilities in the hospice. The use of palliative radiotherapy, including limits to referral, was examined using Pearson's correlation, parametric and nonparametric tests related to hospice size, access to inpatient beds, and organizational type of hospice.
From more than 1,800 hospices surveyed, respondents from 480 individual hospices returned the questionnaire. The response rate of 27% is similar to the historical response rate of 26% for previous NHPCO surveys, though it is not possible to estimate whether the responding sites accurately represent the entire group of hospices. Nearly two-thirds of those who completed the questionnaire were clinical members of the hospice team, though nonphysician clinicians outnumbered physicians by more than two to one. Several questions related to the physical, financial, and clinical data were used to characterize the hospices that responded (Table 1). General program characteristics of respondents match those of the NHPCO membership, except that the average daily census is above and the average length of service reported by the responding hospices is below the national average.2 Six questions investigated the attitudes of the hospice professionals toward the usefulness of radiotherapy in the hospice setting as well as the quality of their interactions with available radiation oncologists (Table 2). One question provided a list of 13 common clinical situations for which most radiation oncologists would consider offering palliative treatment and asked the hospice respondents to select those they would consider for referral. Hospice professionals demonstrated an uneven willingness to consider referral across the possible indications for radiotherapy (Table 3).
The average number of hospice patients who received radiotherapy in 2002 was 3%. The percent estimate from those 392 programs that responded was positively skewed by answers from facilities with an unusually high rate of referral for palliative radiotherapy, as is evidenced by a median of only 1% receiving treatment and a standard deviation of 5%. The hospice professionals were provided with a list of possible factors that limit their referrals to radiation oncology and were asked to select all they felt were applicable. The most common limiting factors selected by approximately 60% of the respondents included radiotherapy expense, short life expectancy of the patient, and transportation difficulties (Table 4).
Responses to the questionnaire items related to practices and attitudes regarding radiotherapy were examined with respect to the professional role of the responder. A greater percentage of hospice physicians than either hospice administrators or nonphysician clinicians believe that radiotherapy is important in the delivery of palliative care. Hospice physicians were more confident than the other respondents in their understanding of the situations when radiotherapy intervention should be considered, and they also more strongly believed that radiation oncologists were sufficiently trained in palliative care. Hospice physicians, administrators, and nonphysician clinicians were similar in their belief that radiation oncologists are reluctant to provide single-fraction therapy. Nevertheless, a higher percentage of hospice physicians stated that they made palliative radiotherapy available to their patients and that they would be willing to recruit patients into palliative radiotherapy treatment protocols. Each of the groups of hospice professionals strongly indicated a willingness to attend lectures about palliative radiotherapy. The utilization rates of radiotherapy were not significantly associated with average daily census or average length of stay of the individual hospices. The percentage of patients who received radiotherapy did not depend on the organizational type of the hospice. Additionally, the most common limits to referral were not significantly associated with organizational type of the program. The presence of inpatient beds did not influence the rate of use of radiotherapy. Interestingly, hospices that had inpatient beds were more likely than hospices with no inpatient beds to select short life expectancy (P = .01), treatment length (P = .01), and reimbursement restrictions (P = .03) as factors that limit referral. There was no difference between the two groups in their selection of expense and difficulty with transportation as barriers to referral.
Numerous trials have documented that radiation therapy provides prompt and effective relief of cancer symptoms with few side effects. Although cancer patients comprise half of those who are admitted to hospice, only 3% of hospice patients receive radiotherapy because of factors that include cost, length of radiotherapy treatment course, transportation, patient infirmary, and educational deficiencies on the part of both radiation oncologists and hospice professionals. Reimbursement issues, however, remain the primary barrier. Hospices receive Medicare reimbursement of $114 per day to provide all medical care to a patient, though the charges for treatment planning and delivery of even a single fraction of palliative radiotherapy costs several times more. Assuming a conversion factor of $36.70 per relative value unit and Medicare reimbursement rates for 2003, a low complexity single-fraction treatment costs $630. Using these same assumptions to assess charges for the more commonly used 10-fraction course, the estimated cost ranges from $1,508 to $2,221 of the $3,420 monthly Medicare reimbursement.18 This disparity between cost and reimbursement currently makes it financially difficult to refer a significant proportion of hospice patients for radiation. Our data suggest that these reimbursement issues are important in all types of hospice settings. Hospice patients who survive several months derive the benefit of improved pain control and function from palliative radiation. Palliative radiotherapy, however, will remain underused in hospice patients unless reimbursement comes to more closely match costs. Three quarters of the surveyed respondents stated that radiation oncologists are reluctant to use single-fraction therapy, suggesting that hospice professionals seek a radiotherapy option that is less expensive and burdensome to the patient. In the case of palliative radiotherapy for symptomatic bone metastasis, sufficient data exist to show that single-fraction treatment provides equal relief when compared with more protracted regimens. Wu et al15 reported a meta-analysis of randomized trials between 1996 and 2001 that investigated dose fractionation in the treatment of bone metastasis. The rate of pain relief in seven combined trials was an identical 73% for those who received single- or multiple-fraction regimens. Patterns of care show worldwide variance in fractionation, with most United States radiation oncologists choosing multiple-fraction regimens over single-fraction treatment.19-22 Radiation oncologists in the United States have been reluctant to waver from a common practice. Also, many of the analyzed trials reveal a higher rate of reirradiation to the same painful site in those who receive single-fraction treatment, and physicians want to maximize the chances for success with the first course of treatment. However, few hospice patients would likely survive long enough to face a need for re-treatment. The prospective, randomized fractionation trial, Radiation Therapy Oncology Group Trial 97-14, revealed virtually identical rates of pain relief at 3 months from either 8 Gy in one fraction or 30 Gy in 10 fractions for patients with bone metastasis from primary breast or prostate cancer.16 Transportation of hospice patients to radiation therapy centers has also been considered a barrier to referral. Our recent study showed that hospice programs with inpatient beds were statistically significantly more likely to list short life expectancy, longer treatment length, and reimbursement restrictions as factors that were limiting referral for radiation therapy. In general, programs with inpatient beds care for a greater percentage of patients with very short life expectancy who require greater than average financial resources. The data also revealed significant educational deficiencies that act as barriers to referral of hospice patients for radiotherapy. Radiation oncologists expect a reasonable chance for successful palliation after radiotherapy for any of the 13 clinical circumstances presented in Table 3, yet radiotherapy referral was only thought necessary by a wide majority of hospice professionals in the setting of pain or spinal cord compression. Pain is a common and debilitating symptom, but it is hard to imagine that the other listed symptoms would not prove compelling for referral if hospice professionals were aware of the potential benefit. The wide majority of hospice professionals describe that they know radiation oncologists with whom they can converse about palliative cases. The training of other hospice professionals is also critical and should include the knowledge of when to approach the hospice physician or radiation oncologist with questions. The vast majority of palliative radiotherapy literature has been written about the topic of bony metastasis. Almost half of the respondents in our survey, however, did not feel sufficiently trained to identify situations in which palliative radiotherapy should be considered. This deficiency reflects the paucity of radiotherapy trials that relate to other end-of-life issues. Nearly half of the hospice respondents felt that the radiation oncologists were not sufficiently trained in palliative care to render an opinion regarding hospice patients. Many attached written comments to the survey that indicated both a failure on the part of the radiation oncologists to understand the financial and logistical barriers to radiotherapy in hospice as well as a more general lack of understanding that hospice care singularly focuses on symptom relief. There remains no formal requirement for palliative care education during the radiation oncology residency training period. However, national radiotherapy and hospice groups have begun to increase their educational collaboration. The Health Services Research Committee of ASTRO has formed a Symptom Research Group to promote palliative care education, research, patient care advocacy, and collaboration with hospice and palliative care professional groups. The NHPCO has dedicated itself to the yearly presentation of a radiotherapy refresher topic at its national Clinical Team Conference meetings. Additionally, the American Board of Hospice and Palliative Medicine, which administers the hospice and palliative medicine board examination, has added a radiation oncologist to the Examination Committee. In conclusion, palliative care experts from ASTRO and NHPCO have agreed to advance common patient care initiatives through improved education between the two specialties, formulation of radiotherapy research protocols in hospice groups, and patient advocacy. The NHPCO recently began accrual to a pilot trial entitled Examining the Efficacy of Palliative Radiotherapy for Symptomatic Bone Metastases in Hospice Patients. The study will measure whether the life expectancy of hospice oncology patients is sufficiently long to document pain relief from a single fraction of radiotherapy and whether that relief influences quality of life.
The authors indicated no potential conflicts of interest.
We thank all the hospice professionals who took time to answer the survey and offer constructive comments.
Presented at the 45th Annual Meeting of the American Society for Therapeutic Radiology and Oncology, October 21, 2003, Salt Lake City, UT. Authors' disclosures of potential conflicts of interest are found at the end of this article.
1. Kutner JS, Kassner CT, Nowels DE: Symptom burden at the end of life: Hospice providers' perceptions. J Pain Symptom Manage 21:473-480, 2001[CrossRef][Medline] 2. National Hospice and Palliative Care Organization: 2002 NHPCO National Data Set Summary Report. http//www.nhpco.org/files/members/2002nationaldataset.pdf 3. Lorenz KA, Ettner SL, Rosenfeld KE, et al: Cash and compassion: Profit status and the delivery of hospice services. J Palliat Med 5:507-514, 2002[CrossRef][Medline] 4. Barnes EA, Palmer JL, Bruera E: Prevalence of symptom control and palliative care abstracts presented at the Annual Meeting of the American Society for Therapeutic Radiology and Oncology. 54:211-214, 2002 5. Hoegler D: Radiation therapy for palliation of symptoms in incurable cancer. Curr Probl Cancer 21:129-183, 1997[CrossRef][Medline]
6. Moore S, Corner J, Haviland J, et al: Nurse led follow up and conventional medical follow up in management of patients with lung cancer: Randomized trial. BMJ 325:1-7, 2002 7. Bezjak A, Dixon P, Brundage M, et al: Randomized phase III trial of single versus fractionated thoracic radiation in the palliation of patients with lung cancer. Int J Radiat Oncol Biol Phys 54:719-728, 2002[CrossRef][Medline] 8. Plantaniotis GA, Kouvaris JR, Dardoufas C, et al: A short radiotherapy course for locally advanced non-small cell lung cancer (NSCLC): Effective palliation and patients' convenience. Lung Cancer 35:203-207, 2002[Medline] 9. Lupattelli M, Maranzano E, Bellavita R, et al: Short-course palliative radiotherapy in non-small-cell lung cancer: Results of a prospective study. Am J Clin Oncol 23:89-93, 2000[CrossRef][Medline] 10. Macbeth FR, Bolger JJ, Hopwood P, et al: Randomized trial of palliative two fraction versus more intensive 13-fraction radiotherapy for patients with inoperable non-small cell lung cancer and good performance status: Medical Research Lung Cancer Working Party. Clin Oncol (R Coll Radiol) 8:167-175, 1996 11. Paszat L, Shenouda G, Blood P, et al: The role of palliative radiotherapy for brain metastases. Can J Oncol 6:48-53, 1996 (suppl 1) 12. Priestman TJ, Dunn J, Brada M, et al: Final results of the Royal College of Radiologists' trial comparing two different radiotherapy schedules in the treatment of cerebral metastases. Clin Oncol (R Coll Radiol) 8:308-315, 1996 13. Duchesne GM, Bolger JJ, Griffiths GO, et al: A randomized trial of hypofractionated schedules of palliative radiotherapy in the management of bladder carcinoma: Results of medical research council trial BA09. Int J Radiat Oncol Biol Phys 47:379-388, 2000[Medline] 14. Wiegel T, Bottke D, Kruesel KM, et al: External beam radiotherapy of choroidal metastasis: Final results of a prospective study of the German Cancer Society (ARO 95-08). Radiother Oncol 64:13-18, 2002[CrossRef][Medline] 15. Wu J, Wong R, Johnston M, et al: Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 55:594-605, 2003[CrossRef][Medline] 16. Hartsell WF, Scott C, Bruner DW, et al: Phase III randomized trial of 8 Gy in 1 fraction vs. 30 Gy in 10 fractions for palliation of painful bone metastases: Preliminary results of RTOG 97-14. Int J Radiat Oncol Biol Phys 57:S124, 2003 (abstr 1)[Medline]
17. van de Hout WB, van der Linden YM, Steenland E, et al: Single- versus multiple-fraction radiotherapy in patients with painful bone metastases: Cost-utility analysis based on a randomized trial. J Natl Cancer Inst 95:222-229, 2003 18. Blitzer P: Physician Medicare Payment Schedule. Adapted from www.cms.gov data published November 1, 2003. http://www.radiotherapy.com/Payment/Phys-0304v3.htm 19. Chow E, Danjoux C, Wong R, et al: Palliation of bone metastasis: A survey of patterns of practice among Canadian radiation oncologists. Radiother Oncol 56:279-281, 2000[CrossRef][Medline] 20. Lievens Y, Kesteloot K, Rijners A, et al: Differences in palliative radiotherapy for bone metastases within Western European countries. Radiother Oncol 56:297-303, 2000[CrossRef][Medline] 21. Roos D: Continuing reluctance to use single fractions of radiotherapy for metastatic bone pain: An Australian and New Zealand practice survey and literature review. Radiother Oncol 56:315-322, 2000[CrossRef][Medline] 22. Lievens Y, Van den Bogaert W, Rijnders A, et al: Palliative radiotherapy practice within Western European countries: Impact of the radiotherapy financing system? Radiother Oncol 56:289-295, 2000[CrossRef][Medline] Submitted November 25, 2003; accepted June 19, 2004.
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
