Radiation Therapy at the End of-Life: Quality of Life and Financial Toxicity Considerations

In patients with advanced cancer, radiation therapy is considered at various time points in the patient's clinical course from diagnosis to death. As some patients are living longer with metastatic cancer on novel therapeutics, radiation oncologists are increasingly using radiation therapy as an ablative therapy in appropriately selected patients. However, most patients with metastatic cancer still eventually die of their disease. For those without effective targeted therapy options or those who are not candidates for immunotherapy, the time frame from diagnosis to death is still relatively short. Given this evolving landscape, prognostication has become increasingly challenging. Thus, radiation oncologists must be diligent about defining the goals of therapy and considering all treatment options from ablative radiation to medical management and hospice care. The risks and benefits of radiation therapy vary based on an individual patient's prognosis, goals of care, and the ability of radiation to help with their cancer symptoms without undue toxicity over the course of their expected lifetime. When considering recommending a course of radiation, physicians must broaden their understanding of risks and benefits to include not only physical symptoms, but also various psychosocial burdens. These include financial burdens to the patient, to their caregiver and to the healthcare system. The burden of time spent at the end-of-life receiving radiation therapy must also be considered. Thus, the consideration of radiation therapy at the end-of-life can be complex and requires careful attention to the whole patient and their goals of care.