Palliative Radiotherapy Within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment.

PURPOSE: Most Veterans Health Administration hospitals do not have radiation oncology (RO) departments on-site. The purpose of this study is to determine the impact of on-site RO on referral patterns and timeliness of palliative radiation therapy (PRT). MATERIALS AND METHODS: A survey was sent to medical directors at 149 Veterans Health Administration centers. Questions evaluated frequency of referral for PRT, timeliness of RO consults and treatment, and barriers to referral for PRT. Chi-square analysis was used to evaluate differences between centers that have on-site RO and centers that refer to outside facilities. RESULTS: Of 108 respondents, 33 (31%) have on-site RO. Chi-square analysis revealed that RO consult within 1 week is more likely at centers with on-site RO (68% v 31%; P = .01). Centers with on-site RO more frequently deliver PRT for spinal cord compression within 24 hours (94% v 70%; P = .01). Those without on-site RO were more likely to want increased radiation oncologist involvement (64% v 26%; P < .001). Barriers to referral for PRT included patient ability to travel (81%), patient noncompliance (31%), delays in consult and/or treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding excessive number of treatments (13%). Respondents with on-site RO less frequently reported delays in consult and/or treatment (6% v 41%; P < .0001) and difficulty contacting a radiation oncologist (0% v 20%; P = .0056) as barriers. CONCLUSION: Respondents with on-site RO reported improved communication with radiation oncologists and more timely consultation and treatment initiation. Methods to improve timeliness of PRT for veterans at centers without on-site RO should be considered.

Radiotherapeutic Care of Patients With Stage IV Lung Cancer with Thoracic Symptoms in the Veterans Health Administration.

BACKGROUND: Radiotherapy plays an important role in the palliation of lung cancer, which is the second most common cancer diagnosed in the Veterans Health Administration (VHA). The American Society for Radiation Oncology (ASTRO) developed evidenced-based treatment guidelines for the management of patients with metastatic lung cancer. METHODS: In May 2016, an electronic survey of 88 VHA radiation oncologists (ROs) was conducted to assess metastatic lung cancer management. Demographic information was obtained and 2 clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or yttrium aluminum garnet (YAG) laser technology. Survey results were assessed for concordance with published ASTRO guidelines. RESULTS: The survey response rate was 61%, with 93% of the 40 VHA radiation departments represented. Among respondents, 96% were board certified, and 90% held academic appointments. 88% were familiar with ASTRO guidelines. Preferred fractionation schemes were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%). The vast majority (98%) did not recommend concurrent chemotherapy for palliation. In the setting of bronchial obstruction with lung collapse, about half (49%) recommended EBB or YAG lung reexpansion before external beam radiotherapy. A minority of respondents use stereotactic body radiotherapy or EBB for palliation. CONCLUSION: Most respondents demonstrated up-to-date knowledge of current evidence-based treatment guidelines. We found no distinction in clinical decisions based on demographic profiles.

Management of metastatic spinal cord compression among Veterans Health Administration radiation oncologists.

BACKGROUND: Optimal management of metastatic spinal cord compression (MSCC) improves functional outcomes in patients with metastatic disease. This survey study evaluated management of MSCC by Veterans Health Administration (VHA) radiation oncologists (ROs), to determine whether management of MSCC correlates with American College of Radiology (ACR) guidelines, and to compare times to initiation of treatment between surgery and radiotherapy (RT). METHODS: Surveys emailed to 79 VHA ROs included questions on steroid use, surgical care, palliative care, fractionation of irradiation, re-irradiation, and management of common MSCC case scenarios. Follow-up phone calls were made to encourage survey participation. Descriptive statistics and chi-square testing were done to show significant associations. RESULTS: The survey yielded an 81.0% response rate; 79.4% of ROs had read the ACR Appropriateness Criteria® Spinal Bone Metastases. The majority (87.3%) prefer 30 Gy/10 fractions for MSCC, and all respondents recommend steroid therapy in conjunction with RT. When used, RT was more often initiated within 24 hours than was neurosurgery (83.9% vs. 34.5%, P<0.001). All ROs report use of palliative care services. Re-irradiation is given by 66.1%: 30.7% with stereotactic body radiation therapy (SBRT), 17.7% using intensity modulated radiation therapy (IMRT), and 17.7% using conventional RT. For the case scenarios, most respondents' (>75%) management concurred with ACR guidelines. CONCLUSIONS: The majority of VHA ROs are familiar with the ACR Appropriateness Criteria® Spinal Bone Metastases and practice accordingly. Treatment within 24 hours is more likely when RT is the primary modality compared to when surgical decompression precedes RT.

Consensus Statement Supporting the Recommendation for Single-Fraction Palliative Radiotherapy for Uncomplicated, Painful Bone Metastases.

Single-fraction palliative radiation therapy is a shorter course treatment option for veterans with terminal cancers and offers effective, convenient pain relief.

The Availability of Advanced Radiation Oncology Technology within the Veterans Health Administration Radiation Oncology Centers.

Radiation oncologists were surveyed to determine how accessible advanced radiation delivery modalities are within the VHA.

Palliative Radiotherapy for the Management of Metastatic Cancer: Bone Metastases, Spinal Cord Compression, and Brain Metastases.

Life expectancy and tumor characteristics should be considered when making treatment recommendations for palliative radiotherapy, which can be cost-effective and provide symptom relief.

Availability of single-fraction palliative radiotherapy for cancer patients receiving end-of-life care within the Veterans Healthcare Administration.

BACKGROUND: Surveys demonstrate < 20% of radiation oncologists in the United States offer single-fraction palliative radiotherapy (RT) even though it is an acceptable standard of care. A study was conducted to investigate whether this held true for those practicing within the Veterans Healthcare Administration (VHA). METHODS: All radiation oncologists currently practicing at VHA medical centers were surveyed. Comparisons and associations of responses were evaluated by Fisher's exact test. RESULTS: The response rate was 90%. Half were full-time employees of the VHA, and the majority (70%) had thoroughly read guidelines on palliative RT for bone metastases recently published by either the American College of Radiology (ACR, 2009, 2012) or the American Society of Radiation Oncology (ASTRO, 2011). Single-fraction palliative RT for bone metastases had been prescribed by 76% of respondents, and 93% had prescribed a short course of ≤ 6 fractions. Respondents were less likely to have prescribed a single fraction for patients who had survival estimates of either > 6 months or > 12 months (66% versus 37%, p < 0.0001).Those not offering single-fraction palliative RT (24%) were more likely to be > 10 years out of training (37% versus 10%, p = 0.01), and to have worked in a private practice setting at some point in their career (36% versus 12%, p = 0.03). CONCLUSIONS: A majority of radiation oncologists within the VHA offer single-fraction therapy to their patients. These data ensure access to palliative RT is not limited within this health care system by a preference for prolonged treatment courses that may discourage patients and clinicians from seeking this care.