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Appropriate Palliative Radiotherapy Often Not Given to End-Stage Cancer Patients

— Both analgesics and radiotherapy are used to manage pain in terminal cancer patients, and an estimated 50% of patients referred for radiotherapy are treated with palliative intent. However, a new study suggests that a considerable proportion of patients with end-stage or terminal cancer do not benefit from palliative radiation therapy.

The study, published online April 12 in Cancer, found that half of all patients referred for palliative therapy spent more than 60% of their remaining lifespan receiving therapy, but complaints worsened in 52%. Conversely, only 26% reported improvement or stabilization of their symptoms.

In addition, the authors note, many physicians overestimated the length of time their patients would survive, and radiotherapy was completed in just over half (58%) of the patients.

"The lifespan of cancer patients in our study was overestimated in the vast majority of cases," explained lead author Stephan Gripp, MD, MD, from the Department of Radiation Oncology at the University Hospital Düsseldorf in Germany. "These too-optimistic estimates prevented doctors from applying hypofractionated radiotherapy."

Clearly, more research is needed to establish evidence-based survival estimates.
Most survival estimates rely on the informal guesses of the physicians caring for the patient, he continued. "These estimates are not only generally imprecise, they are also systematically overoptimistic," Dr. Gripp pointed out. "Few objective systems have been developed integrating various aspects of physical health status, stage of disease, psychological distress, and doctors' estimates. Clearly, more research is needed to establish evidence-based survival estimates."

In addition, he told Medscape Oncology that traditional concerns about late radiation damage due to single fractionation radiotherapy might play a role. "In these patients, such concerns are unrealistic," he said.

There are good data from randomized studies indicating a broader use of single or a few fractions in radiotherapy, Dr. Gripp noted. "This should become an accepted standard of care in palliative radiotherapy, and reimbursement must be fitted to these needs."

Survival Overestimated

To investigate the adequacy of palliative radiotherapy in patients with end-stage cancer patients, Dr. Gripp and colleagues evaluated the management of individuals undergoing palliative radiotherapy at their institution from December 2003 to July 2004 and who died within 30 days. They identified 33 patients whose survival was estimated on the basis of symptoms, Karnofsky Performance Status, and laboratory tests. The median age was 65 years, and median survival was 15 days. Two patients died before the authors were able to make a survival assessment.

The primary cancer types in the cohort were lung (39%) and breast (18%), and metastases were present in 94% of patients.

Radiotherapy was prescribed for the 31 remaining patients, and chemoradiation was prescribed for 3. A total of 91% actually received treatment. The median waiting time from first visit to the start of radiotherapy was 4 days, and median treatment duration was 15 days. Of the 85 independent survival estimates that were obtained, only 16% were correct in asserting survival would be a month at most.

Many of the physicians overestimated the remaining lifespan of their patients and incorrectly estimated that 21% of patients would survive for more than 6 months.

Better Predictors Needed

The authors note that most cancer patients destined for palliative therapy have a very limited lifespan and, therefore, an accurate estimate of survival is necessary to avoid futile therapies. Time-consuming therapies can also interfere with a patient's desire to die at home, they add.

Although they caution that "conclusions must be drawn carefully from a single-institution experience and a small sample size," the study does point to the current limits of the ability to predict death in patients with end-stage disease, and to the ability to provide effective survival-time-adapted palliation.

"Objective prognostic systems may improve the reliability of survival prediction, and eventually allow life-expectancy-adjusted therapeutic strategies," they conclude. "Survival overestimates may have contributed to mismatched fractionation schedules, a considerable waste of time, and the high percentage of patients who discontinued therapy."

They add that "closer adherence to results of randomized trials will possibly reduce unrealistic concerns about late-onset toxicity and will promote hypofractionated radiotherapy."


Roxanne Nelson is a staff journalist for Medscape Oncology.
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