9/19/2017 1 Palliative Radiotherapy We Can Actually Afford: A New Program Designed to Help Patients and Caregivers Save Resources 1 Christopher Abraham, MD Assistant Professor Department of Radiation Oncology Washington University School of Medicine Patrick White, MD, HMDC, FACP, FAAHPM Chief Medical Officer, BJC Home Care Assistant Professor of Medicine Washington University School of Medicine Disclosure: There are no relevant financial relationships to disclose regarding this presentation 2 Patrick White, MD Chris Abraham, MD 1) Describe 3 potential benefits of palliative radiation 2) Identify 3 obstacles to the use of palliative radiation in the hospice setting 3) Describe how a new program can make palliative radiation available to all hospice patients Objectives 3
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9/19/2017
1
Palliative Radiotherapy We Can Actually
Afford: A New Program Designed to Help
Patients and Caregivers Save Resources
1
Christopher Abraham, MD
Assistant Professor
Department of Radiation Oncology
Washington University School of Medicine
Patrick White, MD, HMDC, FACP, FAAHPM
Chief Medical Officer, BJC Home Care
Assistant Professor of Medicine
Washington University School of Medicine
Disclosure: There are no relevant financial
relationships to disclose regarding
this presentation
2
Patrick White, MD
Chris Abraham, MD
1) Describe 3 potential benefits of palliative radiation
2) Identify 3 obstacles to the use of palliative radiation in
the hospice setting
3) Describe how a new program can make palliative
radiation available to all hospice patients
Objectives
3
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2
My Background
• Internal Medicine-
Washington
University/BJH
• PhD Program, Clinical and
Translational Science,
University of Pittsburgh
• Co-Chief Medical Officer,
University of Pittsburgh’s
Hospice Program
• Chief Medical Officer, BJC
Home Care
My Background
5
• MD, Saint Louis
University
• Radiation Oncology
Residency, Barnes-
Jewish Hospital
• Assistant Professor,
Department of
Radiation Oncology
Washington University
in St. Louis
States Worse Than Death Among Hospitalized
Patients With Serious Illnesses
6
Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med. 2016 PMID 24479808
9/19/2017
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Radiotherapy Basics
• Radiotherapy utilizes high energy radiation to damage DNA
– X-rays, gamma rays, charged particles
– DNA damage is not specific to cancer cells alone
• Radiotherapy may be delivered locally or systemically
• Local radiotherapy may be delivered externally or internally
• Radiation dose is prescribed in Gray and fractions
• Fractionation is utilized to:
– Minimize normal tissue toxicity
– Increase the likelihood DNA damage
Radiotherapy Basics
• Radiotherapy may be given with definitive OR palliative
intent
• Nearly 50% of all radiotherapy is given with palliative
• Is the patient able to follow instructions, can the safely
be placed on a treatment table?
• Is the patient decisional to sign consent for treatment?
– if not POA must be present for consult and treatment to give
consent.
Information Needed From the Referring Hospice
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Logistics
Hospice determines radiotherapy need
Case discussed with Radiation Oncology
Formal referral rendered
Continued assessment of need
Radiation Oncology assessment
Simulation
Quality Assurance
Delivery of single fraction radiotherapy
Transportation
Pre-medication
• Conway JL, Yurkowski E, Glazier J, et al. Comparison of Patient-reported Outcomes with a Single
Versus Multiple Fraction Palliative Radiotherapy for Bone Metastasis in a Population-based Cohort. Radiother Oncol. 2016; 119(2):202-207.
• Chow E, van der Linden YM, Roos D, et al. Lancet Oncol. Single Versus Multiple Fractions of Repeat Radiation for Painful Bone Metastases: a Randomized, Controlled, Non-inferiority Trial.
2014 Feb;15(2):164-71.
• Collinson L, Kvizhinadze G, Nair N, McLeod M, Blakely T. Economic Evaluation of Single-fraction
Versus Multiple-fraction Palliative Radiotherapy for Painful Bone Metastases in Breast, Lung and
Prostate Cancer. J Med Imaging Radiat Oncol. 2016; 60(5):650-660.
• Chow E, Hahn CA, Lutz ST, Global Reluctance to Practice Evidence-based Medicine Continues in
the Treatment of Uncomplicated Painful Bone Metastases Despite Level 1 Evidence and Practice Guidelines. Int J Radiat Oncol Bio Phys. 2012;83(1):e117-120.
• Saito T, Toya R, Semba A, et al. Influence of the Treatment Schedule on the Physicians' Decisions
to Refer Bone Metastases Patients for Palliative Radiotherapy: a Questionnaire Survey of
Physicians in Various Specialties. Nagoya J Med Sci. 2016; 78(3):275-84.
• Fairchild A, Barnes E, Ghosh S, et al. International Patterns of Practice in Palliative Radiotherapy
for Painful Bone Metastases: Evidence-based Practices? Int. J. Radiation Oncology Biol. Phys.
2009;75(5):1501-1510.
• Thavarajah N, Zhang L, Wong K, Bedard G. Patterns of Practice in the Prescription of Palliative
Radiotherapy for the Treatment of Bone Metastases at the Rapid Response Radiotherapy Program Between 2005 and 2012. Curr Oncol. 2013 Oct;20(5):e396-405.
References
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• McDonald R, Ding K, Brundage M, et al. Effect of Radiotherapy on Painful Bone Metastases: A
Secondary Analysis of the NCIC Clinical Trials Group Symptom Control Trial SC.23. JAMA Oncol. 2017. Epub ahead of print.
• Howell DD, James JL, Hartsell WF, Suntharalingam M. Single-fraction Radiotherapy Versus Multi-fraction Radiotherapy for Palliation of Painful Vertebral Bone Metastases-equivalent Efficacy, Less
Toxicity, More Convenient: a Subset Analysis of Radiation Therapy Oncology Group trial 97-14.