Burden of palliative care issues encountered by radiation oncologists caring for patients with advanced cancer

Purpose: Radiation oncologists frequently provide care for patients with advanced cancer who are in their last months or weeks of life. This study examined the previously not well-characterized types and frequencies of palliative care issues encountered in consultations for palliative radiation therapy (PRT). Methods and materials: This prospective, survey-based study assessed consecutive consults for PRT from May 19, 2014, to September 26, 2014 at 3 Boston-area community and academic, hospital-based centers. Participating physicians and nurse practitioners completed a survey to identify and rank the relevance (5-point Likert scale, not at all to extremely) of palliative care issues. Eight domains adapted from national palliative care guidelines (physical symptoms, psychosocial issues, cultural considerations, spiritual needs, care coordination, advance care planning, goals of care, and ethical and legal issues) were evaluated. A total of 162 consecutive consultations were surveyed with 140 responses received (86% response rate). Results: Most (82%) consults had 2 or more palliative care domains ranked as highly (very or extremely) relevant to care. The domains of physical symptoms (91%), care coordination (70%), goals of care (59%), and psychosocial issues (52%) were the most commonly reported domains as highly relevant to care. Forty-six percent of consults involved a high palliative care burden (4 or more palliative care domains identified as highly relevant tocare). Predictors of high palliative care burden in multivariable analysis were Eastern Cooperative Oncology Group performance status N 2 (odds ratio, 3.57; P = .047), a plan for no further anticancer therapy after PRT (odds ratio, 3.46; P = .03), and a recommendation against PRT (odds ratio, 4.80; P = .01)


Introduction
Radiation therapy is frequently administered with palliative intent in patients with advanced cancer.Over a 35-year period at the University of Texas M.D. Anderson Cancer center, 35% of patients treated in their department received palliative-intent radiation therapy. 1 Even in the most recent year studied (1995), the proportion of patients treated with palliative-intent radiation therapy (PRT) remained unchanged at 34%. 1 In a 2013 survey study, radiation oncologists estimated that 29% of their consultations were for palliative intent radiation therapy. 2 Among patients with metastatic cancer, 30% receive radiation therapy in their last year of life, 3 and of those receiving radiation therapy in the final month of life, 18% spent 10 or more of their last 30 days receiving radiation treatments. 4espite frequently encountering patients who are in the last year or months of their life, the field of radiation oncology has had little academic emphasis on palliative care, including a paucity of education and research in this area. 1,5,6Radiation oncologists are less likely than noncancer specialists to engage their terminally ill patients in end-of-life discussions. 7Meanwhile, there is a consensus building that palliative care should be integrated into all stages of cancer care. 8,9,10In its 2013 report, Delivering High-Quality Cancer Care, the Institute of Medicine emphasized addressing patients' palliative care needs at all points along the cancer care continuum. 8n addition, the American Society of Clinical Oncologists describes a need for evidence-based design of palliative care training for practicing oncologists, residents, and fellows. 9lthough radiation therapy has long been used with palliative intent, there are limited data characterizing the palliative care issues encountered by radiation oncologists.We conducted a survey-based study of radiation oncology clinicians to define the types, frequencies, and perceived relevance of palliative care issues that arise when considering PRT for patients with advanced cancer.

Survey and participants
A survey designed to evaluate the palliative care issues encountered by radiation oncology clinicians was written and initially critiqued by 3 investigators (MK, VL, TB).Palliative care domains were adapted from national palliative care practice and national oncology care practice guidelines. 10,11Eight palliative care domains (physical symptoms, psychosocial issues, cultural consideration, spiritual needs, care coordination, advanced care planning, goals of care, and ethical and legal issues) were evaluated.Clinicians ranked the relevance (5-point Likert scale, not relevant to extremely relevant) of each palliative care domain to the patient's care within radiation oncology.Additionally, clinicians indicated the presence (yes, no, or not assessed) of 31 palliative care subissues related to the primary domains.Clinicians also reported whether the consulted patient's metastatic cancer diagnosis was new (within last 1 month) or established (greater than 1 month) and whether the patient, after radiation therapy consultation and intervention (where applicable), was returning to active oncological care (eg, chemotherapy) versus to no further anticancer therapies (eg, hospice care).
A panel of 7 clinicians with expertise in medical oncology, radiation oncology, palliative care, and/or survey construction assessed the survey's face and content validity, ease of completion, and completion time.After incorporating each panel member's initial comments, the survey was then sent to 1 member of the panel at a time in a sequential manner.Edits were made to the survey after each panel member's review until 2 consecutive panel members had no suggestions for improvement.This occurred after review by the sixth panel member.
After receiving approval from the institutional review boards of participating radiation oncology centers, we electronically surveyed radiation oncology clinicians conducting PRT consultations.We prospectively evaluated all consultations for consideration of palliative intent radiation therapy from May 19, 2014, to September 26, 2014, performed by a dedicated palliative radiation therapy service at a large academic cancer center and by 2 participating clinicians at affiliated regional hospitals.Eligible consultations included those for patients older than age 18 years with incurable, metastatic cancers.Immediately after each PRT consult, the consulting clinician was emailed a survey to be completed within 5 business days.Reminders to complete the survey were sent 3 times over the 5 business day interval.Fifteen radiation oncology clinicians, consisting of nurse practitioners, resident physicians, and attending physicians, were sent 162 surveys over the study period.For their participation, survey respondents received one $25 gift card regardless of the number of surveys completed.
Study investigators then extracted patient demographic (age, gender, marital status) and disease data (primary cancer