Talking about treatment benefits, harms, and what matters to patients in radiation oncology: an observational study.

BACKGROUND: Shared decision making is associated with improved patient outcomes in radiation oncology. Our study aimed to capture how shared decision-making practices-namely, communicating potential harms and benefits and discussing what matters to patients-occur in usual care. METHODS: We invited a convenience sample of clinicians and patients in a radiation oncology clinic to participate in a mixed methods study. Prior to consultations, clinicians and patients completed self-administered questionnaires. We audio-recorded consultations and conducted qualitative content analysis. Patients completed a questionnaire immediately post-consultation about their recall and perceptions. RESULTS: 11 radiation oncologists, 4 residents, 14 nurses, and 40 patients (55% men; mean age 64, standard deviation or SD 9) participated. Patients had a variety of cancers; 30% had been referred for palliative radiotherapy. During consultations (mean length 45 min, SD 16), clinicians presented a median of 8 potential harms (interquartile range 6-11), using quantitative estimates 17% of the time. Patients recalled significantly fewer harms (median recall 2, interquartile range 0-3, t(38) = 9.3, p < .001). Better recall was associated with discussing potential harms with a nurse after seeing the physician (odds ratio 7.5, 95% confidence interval 1.3-67.0, p = .04.) Clinicians initiated 63% of discussions of harms and benefits while patients and families initiated 69% of discussions about values and preferences (Chi-squared(1) = 37.8, p < .001). 56% of patients reported their clinician asked what mattered to them. CONCLUSIONS: Radiation oncology clinics may wish to use interprofessional care and initiate more discussions about what matters to patients to heed Jain's (2014) reminder that, "a patient isn't a disease with a body attached but a life into which a disease has intruded."

Radiation Therapy-Induced Dysfunction in Cardiovascular Implantable Electronic Devices.

PURPOSE: The prevalence of patients with cardiovascular implantable electronic devices (CIEDs) who receive radiation treatment for cancer is increasing. External beam radiation therapy (RT) can affect the electronic components. This study aimed to evaluate the incidence and predictors of new onset CIED dysfunction in patients treated with RT. METHODS AND MATERIALS: We retrospectively analyzed data from 230 patients with CIEDs who received radiation treatment at the Radiation Oncology Center of CHU de Québec - Université Laval between February 2007 and November 2013. The reviewed data included baseline characteristics, CIEDs, and RT treatment specifications. Patients with CIEDs were analyzed before, during, and at the end of radiation treatment. High- and low-energy photon or electron beam radiation from linear accelerators, orthovoltage machines, and high-dose rate brachytherapy delivery were used. Abnormal events could be one of the following: total or partial deprogramming of the CIED parameters, onset of new symptoms, or new arrhythmia. RESULTS: This study is based on one of the largest cohorts. A total of 18 events in 16 patients (7.8%) were recorded. Of the 18 events, 16 had at least part of the radiation treatment delivered with photo neutrons producing high-energy RT (neutron producing RT). Only 2 abnormal events occurred during non-neutron producing RT. Both the prescription dose and the dose estimated at the location of the pacemaker were correlated with the probability of an abnormal event (P = .0006 and P = .003, respectively). Among the 16 patients, clinical symptoms were noted in only 1 patient (6.3%). CONCLUSIONS: CIED malfunctions are relatively uncommon and do not seem to be life threatening. We recommend limiting the dose at the CIED and avoid neutron-producing RT to reduce the risk of CIED malfunction.

Radiotherapy-Induced Cardiac Implantable Electronic Device Dysfunction in Patients With Cancer.

Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors, and clinical impact of CIED dysfunction (CIED-D) after radiotherapy for cancer treatment. Clinical characteristics, cancer, different types of CIEDs, and radiation dose were evaluated. The investigation identified 230 patients, mean age 78 ± 8 years and 70% were men. A total of 199 patients had pacemakers (59% dual chamber), 21 (9%) cardioverter-defibrillators, and 10 (4%) resynchronizators or defibrillators. The left pectoral (n = 192, 83%) was the most common CIED location. Sixteen patients (7%) experienced 18 events of CIED-D after radiotherapy. Reset to backup pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrioventricular dyssynchrony. Those who had CIED-D tended to have a shorter device age at the time of radiotherapy compared to those who did not (2.5 ± 1.5 vs 3.8 ± 3.4 years, p = 0.09). The total dose prescribed to the tumor was significantly greater among those who had CIED-D (66 ± 30 vs 42 ± 23 Gy, p <0.0001). Multivariate logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio 1.19 for each increase in 5 Gy, 95% confidence interval 1.08 to 1.31, p = 0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to backup pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias, or conduction disorders.