Palliative radiation therapy in end-of-life care: Evidence-based utilization

Abstract

Palliative radiation therapy is a potentially valuable, but rarely used, tool in end-of-life care programs (e.g., hospice) that could greatly enhance the quality of life in appropriately selected patients with advanced cancer who still have more than a few weeks or months to live.1 Although there are no data on hospice utilization of radiation therapy, it is commonly known within the field that, of the more than one-half million patients who are cared for in hospice programs annually, very few are ever considered for this form of therapy. This is primarily due to the perception that this form of therapy is overly burdensome to the patient and financially untenable under the provisions of the Medicare hospice benefit (the main payer for hospice care), which pays about $100 per day for all services related to the terminal diagnosis. Since conventionally applied radiation therapy fractionation regimens may average 12 or more treatment sessions, requiring frequent trips and considerable time spent at a treatment center, and at costs that are prohibitive under this Medicare prospective payment plan, hospice programs are loathe to advocate for this form of therapy. Conversely, because Medicare payment streams are mutually exclusive, patients with relatively limited prognoses who opt for radiation therapy forcibly deny themselves and their families the more fully featured supportive end-of-life care provided by hospice. On the surface, this would appear to be an irreconcilable “systems” problem, only to be resolved by restructuring Medicare financing. However, a review of the radiation therapy literature from the last several years suggests that markedly abbreviated radiation therapy treatment schedules can be highly therapeutic, cost-effective, and relatively without burden, making palliative radiotherapy a worthy treatment option for patients in hospice programs.2 In fact, this review reveals that there are few radiation therapy outcome studies that can empirically direct the care we give to patients with far-advanced cancer. Much of the practice of radiation oncology seems to be based upon the cumulative observations and experiences of individual therapists, built upon those passed down by their mentors and reinforced through individual practice patterns. As a result, widely variable approaches are taken to manage similar cases, without well-defined differences in clinical results. The intent of this article is to summarize the evidence found in the contemporary radiation therapy literature, with the hope that hospice programs will rethink their hesitant stance on this potentially beneficial therapy, and that radiation therapists will adapt their practices to better serve the needs of patients with limited life expectancy.