One third of physicians are still treating patients who have cancer and bone metastases with extended-fraction radiotherapy (RT), even though a single 8-Gy fraction for this purpose has been strongly recommended since 2013, a new analysis has found.
Indeed, the analysis of more than 12,000 patients treated for bone metastases found that only 9% received the recommended single-fraction treatment.
"In this era of COVID-19, we are trying to minimize contact with the healthcare system as much as possible, so coming into the hospital 20 times over 4 weeks when you could come in once is extraordinarily important," lead author Arjun Gupta, MD, Johns Hopkins University, Baltimore, Maryland, told Medscape Medical News.
"And while I am not suggesting that every patient can be successfully treated with a single fraction, because patients can have complicated bone metastases," he continued, this finding that only 9% of patients are receiving a single fraction is "shockingly low."
The study was published online April 13 in JCO Oncology Practice.
Fee-For-Service Claims
The study authors used Medicare fee-for-service Carrier claims to estimate the use of single vs extended-fraction RT for the treatment of bone metastasis.
"We identified 12,221 Medicare beneficiaries who underwent RT for bone metastases between 2016 and 2018," they note.
The median age of the cohort was 75.6 years, and almost 41% of the group were women. Over 1400 physicians were included in the analysis.
RT episodes were categorized as nonextended if they involved one to 10 fractions; they were categorized as extended if they involved 11 to 20 fractions.
For all comers, "the overall use of extended-fraction RT was 23.4%," the authors report.
"However, we also looked just at patients who died within 6 months [of having received RT for bone metastases], and in this group, 1 in 6 patients — 16% — died within 6 months of getting extended-fraction RT," Gupta added.
"This means that patients are coming in for a whole month of 20 fractions when they are living 6 months or less," he emphasized.
The American Society for Radiation Oncology's Choosing Wisely guidelines, first issued in 2013, in particular emphasize that "strong consideration" be given to the use single-fraction RT for the treatment of bone metastases for patients who have a poor prognosis and for whom durable local control may not be required, as well as for patients who have difficulty with transportation.
Practice Patterns
To identify practice patterns, the authors analyzed a subgroup of 382 physicians who had treated more than 10 patients.
They found that 13.9% of this subgroup of providers had never used extended-fraction RT. Another 39% of this group used extended-fraction RT between 0% and 10% of the time.
However, over half (55%) of the physicians in this subgroup used extended-fraction RT between 0% and 20% of the time.
Furthermore, for one third (33.2%) of these physicians, the extended-fraction RT use rate was 30% or higher. This was the threshold set by expert consensus for the study; use of extended-fraction RT at rates higher than 30% was considered excessive.
On multivariate analysis, patients who were aged 85 years or older were less likely to be treated with extended-fraction RT compared with younger patients.
This is reassuring, the authors suggest, inasmuch as physicians are clearly considering remaining survival time in their treatment decisions when treating elderly patients.
One of the predictors of use of extended-fraction RT in the study was the length of time since physicians had graduated from medical school. The analysis indicated that older physicians ― those who had graduated 30 years ago or longer ― were more likely to use extended-fraction RT compared to those who had graduated 10 or 20 years ago.
"What we speculate is that these practitioners have not potentially kept up with the evidence — they did not undergo training when this evidence was being carried out — so perhaps they are just entrenched in their ways," Gupta suggested.
This finding raises the question as to whether targeting continuing medical education to these individuals would be helpful, he added.
Physicians who practiced in the South were more likely to use extended-fraction RT than those who practiced in the Northeast and the Midwest, the authors also report.
This is particularly troubling, the investigators suggest, because median travel time to any cancer care center is higher in the South than in other parts of the country.
The Choosing Wisely authors acknowledge that single-fraction RT is associated with higher retreatment rates.
However, Gupta and colleagues argue that balanced against this are the drawbacks of multiple fractions. "Unnecessary protracted RT causes financial toxicity and prolonged time spent in treatment and in travel, resulting in decrements in quality of life," they note.
Moreover, Gupta pointed out, coming to the hospital for RT can be difficult for patients.
"When you have painful bone metastases — they may be in your spine, in your arm, or in your leg — you have to get up, get into your car, drive an hour, get out of the car, wait an hour, get RT for an hour, drive back home, so your whole day is gone," he emphasized.
"It's very intense," Gupta said.
Actionable Targets
The authors suggest that their data highlight "actionable targets" for intervening in instances such of this that involve high-cost, low-value healthcare.
The team previously highlighted "actionable targets" in the care of patients with skin cancer.
Gupta and the senior author of the article, Martin Makary, MD, MPH, also at Johns Hopkins University, observed that there was widespread variation in resection patterns in Mohs micrographic surgery for the removal of skin cancer.
"We partnered with their professional organization and sent the outliers nonpunitive letters with feedback and data, so it was like a personalized report card benchmarked to their peers," Gupta explained.
The investigators found that 83% of the outliers demonstrated a reduction in mean stages per case, compared to 60% of outliers in the control group. In that group, 69% also demonstrated a reduction in mean stages per case — the desired outcome, Gupta observed.
"It's really just a peer-to-peer data transparency intervention," Gupta commented.
"We successfully did that with a different disease group [skin cancer] and different professional organization," he said, "but we could do the same thing in this situation [RT for bone metastases]."
The study was supported by the Laura and John Arnold Foundation. Gupta and Makary have disclosed no relevant financial relationships.
JCO Oncol Pract. Published online April 13, 2020. Abstract
Follow Medscape Oncology on Twitter for more cancer news: @MedscapeOnc.
"much" - Google News
May 01, 2020 at 05:03PM
https://ift.tt/2SpPVi6
Too Much Radiotherapy Still Being Used for Bone Metastases - Medscape
"much" - Google News
https://ift.tt/37eLLij
Shoes Man Tutorial
Pos News Update
Meme Update
Korean Entertainment News
Japan News Update
Bagikan Berita Ini
0 Response to "Too Much Radiotherapy Still Being Used for Bone Metastases - Medscape"
Post a Comment