3420 - When Less Is More: Reducing the Administration of Inappropriate Radiotherapy to Patients with Very Poor Prognosis

02:30pm - 03:45pm PT

Hall F

Screen: 31

POSTER

Presenter(s)

Alok Deshane, MD - MSKCC, New York, NY

A. Deshane¹, M. E. Freret², V. S. Brennan¹, L. A. Boe³, P. Iyengar¹, D. R. Gomez¹, D. Yerramilli¹, and A. J. Xu¹; ¹Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, ²Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, ³Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY

Purpose/Objective(s):

Palliative radiotherapy (RT) can be a powerful tool to alleviate symptoms but is often inappropriate for patients with very poor prognosis and imminent death. Physicians remain poor at predicting prognosis, and treatment intensification is often inappropriate for patients hospitalized with metastatic cancers. To better understand predictors of futile care in the inpatient setting, we examined care delivery in a population of patients with extremely limited prognosis at the time of consultation for RT. We hypothesized that patient performance status at time of consultation predicts receipt of RT, and that implementation of a dedicated inpatient radiation oncology (IROC) service improved delivery of prognosis-appropriate care.

Materials/Methods:

We examined a consecutive patients admitted to a large tertiary-care hospital who died within 14 days of inpatient radiation oncology consult. We compared outcomes prior to implementation of the IROC service (consults placed January 2019-December 2019, n = 109, pre-IROC) to those placed during 3 years of the IROC service (January 2021-December 2023, n = 341). The IROC service is comprised of rotating radiation oncology faculty with expertise in metastatic disease, palliative RT, and ablative techniques, along with dedicated advanced practitioners and nurses, and rotating residents. We excluded patients with consults placed in 2020 to minimize confounding from COVID-19 pandemic. Karnofsky Performance Status (KPS) was extracted from the time of inpatient radiation oncology consultation. Statistical analyses were performed with Chi-square testing for non-continuous variables and with Mann-Whitney testing for continuous variables.

Results:

Pre-IROC, RT was delivered to 29.4% (32/109) of patients with 14-day mortality. In the post-IROC period of 2021-2023, RT delivery to this population of patients with limited mortality decreased to 20.2% (69/272, p=0.03). Overall, patients who received RT had significantly higher median KPS compared to patients for whom RT was deferred (p=0.018). Of those who received RT (n =101), when analyzed by site, the most common indications were cord compression (n=37; 29.6%), bone pain (n=25; 20.0%), leptomeningeal disease (n=18, 14.4%), bleeding (n=14, 11.2%), airway obstruction (n=13, 10.4%) and brain metastasis (n=10, 8%). SBRT and palliative single-fraction RT with 8Gy were used for 12.5% (n =16) and 14.8% (n =19) of treatments, respectively.

Conclusion:

Among patients with very poor prognosis (death within 14 days of inpatient radiation oncology consult), RT delivery decreased under the IROC service. Higher KPS predicted receipt of RT. Our findings highlight the need for better tools to inform prognosis-appropriate care. The use of SBRT in this patient population, as well as underuse of single-fraction palliative radiation, highlight opportunities to improve resource utilization.