Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Use of palliative radiotherapy in brain and bone metastases (VARA II study)

Use of palliative radiotherapy in brain and bone metastases (VARA II study) Introduction: Metastases are detected in 20% of patients with solid tumours at diagnosis and a further 30% after diagnosis. Radiation therapy (RT) has proven effective in bone (BM) and brain (BrM) metastases. The objective of this study was to analyze the variability of RT utilization rates in clinical practice and the accessibility to medical technology in our region. Patients and methods: We reviewed the clinical records and RT treatment sheets of all patients undergoing RT for BM and/or BrM during 2007 in the 12 public hospitals in an autonomous region of Spain. Data were gathered on hospital type, patient type and RT treatment characteristics. Calculation of the rate of RT use was based on the cancer incidence and the number of RT treatments for BM, BrM and all cancer sites. Results: Out of the 9319 patients undergoing RT during 2007 for cancer at any site, 1242 (13.3%; inter-hospital range, 26.3%) received RT for BM (n = 744) or BrM (n = 498). These 1242 patients represented 79% of all RT treatments with palliative intent, and the most frequent primary tumours were in lung, breast, prostate or digestive system. No significant difference between BM and BrM groups were observed in: mean age (62 vs. 59 yrs, respectively); gender (approximately 64% male and 36% female in both); performance status (ECOG 0–1 in 70 vs. 71%); or mean distance from hospital (36 vs. 28.6 km) or time from consultation to RT treatment (13 vs. 14.3 days). RT regimens differed among hospitals and between patient groups: 10 × 300 cGy, 5 × 400 cGy and 1x800cGy were applied in 32, 27 and 25%, respectively, of BM patients, whereas 10 × 300cGy was used in 49% of BrM patients. Conclusions: Palliative RT use in BM and BrM is high and close to the expected rate, unlike the global rate of RT application for all cancers in our setting. Differences in RT schedules among hospitals may reflect variability in clinical practice among the medical teams. Keywords: Palliative radiation therapy, Variability, Bone metastases, Brain metastases Introduction and a further 30% develop metastases at some time after Cancer remains a major health and social problem. the diagnosis [3]. Treatment for patients with metastases Therapeutic advances over the past decade have pro- is usually with palliative intent and focuses on the con- duced important improvements in cancer control and in trol of symptoms and the maximization of symptom-free the survival of cancer patients, and a better management time. Metastases are most frequently localized in bone, brain, lung and liver and usually derive from primary of their symptoms has enhanced their quality of life [1]. tumours in breast, prostate, colon/rectum and lung, i.e., Progress has been made in surgery, chemotherapy and the most frequent solid tumours [1]. radiation therapy (RT) and in their greater coordination As in primary tumours, the best outcomes in metastatic in a multidisciplinary approach [2]. cancer are obtained by adopting a multidisciplinary It is estimated that around 20% of patients with solid approach. The use of RT in this setting is supported by tumours are diagnosed after the spread of the disease considerable and robust evidence. It is considered one of the most effective and cost-effective treatments in patients * Correspondence: jose.exposito.sspa@juntadeandalucia.es with bone (BM) or brain (BrM) metastases [4], and pal- Radiation Oncology Department, Virgen de las Nieves University Hospital, liative RT represents around 10-20% of the total work- Avd Fuerzas Armadas 4, Granada 18014, Spain load in a typical radiotherapy unit [5]. Hypofractionated Full list of author information is available at the end of the article © 2012 Expósito et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Expósito et al. Radiation Oncology 2012, 7:131 Page 2 of 7 http://www.ro-journal.com/content/7/1/131 regimens of short duration are generally prescribed for Patients and methods these patients, although a wide range of regimens and This retrospective longitudinal study included all public combinations has been applied [6,7]. Comparative data hospitals in Andalusia (Spain) equipped with RT devices on RT utilization rates across different hospitals are of (n = 12, H1-H12); the study period was from January 1 interest to indicate the access of patients to this technol- to December 31 2007; data were gathered on all patients ogy, its appropriateness and the variability in medical treated with external RT for BM or BrM, including practice [8]. There have been reports of variations in details of all palliative RT treatments. Patients were the use of RT for different tumours [9-11] and in the identified from the clinical management computer W W dose schedules selected for BM and BrM among differ- system linked to the RT equipment (Varis , lantis or ent centres [12-16]. In our region, a previous study found Impac Departmental networks) and from the hospitals’ a suboptimal RT utilization rate and significant variabil- admission records. The same sources were used to ity in the use of RT differences among hospitals [17,18]. gather data on all patients irradiated in any cancer This finding prompted the present investigation into the site during the study period. Clinical records and RT use of RT in BM and BrM, two well-established indica- sheets were reviewed by specifically trained researchers. tions for this treatment. When errors or incongruous results were detected, a Andalusia has a surface area of 87597Km and 7.8 million second review was performed by another member of inhabitants; around half (45.6%) of the population lives the research team. within a 20 km radius around the eight cities in the re- Data were gathered on the type of hospital and RT gion. The regional public health system provides unit and on the demographic and clinical characteristics universal free coverage, while 10% of the total care is and RT treatments of the patients. Study variables delivered in private healthcare facilities. Figure 1 shows included characteristics of the hospital (province), patient the distribution of RT departments in the region. (age, gender, type [brain/bone], performance status with This study focuses on the RT utilization rate and the Eastern Cooperative Oncology Group [ECOG] scale or patterns of palliative RT application in patients with BM Karnofsky scale and primary tumour site), and treatment and BrM. It is part of a broader investigation (Variability (medical indication: total doses, fractions, delay after and Appropriateness of Radiotherapy in Andalusia decision, radiosurgery/surgery in brain metastasis, and [VARA] projects I and II) into the quality of RT deliv- adverse effects [acute grade 2-3 toxicity]). The distance ered in 12 public hospitals in the Andalusian public from RT facilities was based on the area code directory. health system [17]. Because of the difficulty of identifying all patients in Figure 1 Location of radiotherapy departments in Andalusia. TC – Torrecárdenas Hospital (Almería). VN - Virgen de las Nieves University Hospital (Granada). SC - San Cecilio University Hospital (Granada). J - Jaén Hospital (Jaén). RS - Reina Sofía University Hospital (Córdoba). CH - Carlos Haya University Hospital (Málaga). VV - Virgen de la Victoria University Hospital (Málaga). PE - Punta de Europa Hospital (Algeciras, Cádiz). PM - Puerta del Mar University Hospital (Cádiz). VM - Virgen del Rocío University Hospital (Sevilla). VR - Virgen de la Macarena University Hospital (Sevilla). JRJ - Juan Ramón Jiménez Hospital (Huelva). Expósito et al. Radiation Oncology 2012, 7:131 Page 3 of 7 http://www.ro-journal.com/content/7/1/131 Table 1 Characteristics of patients the region with indications for palliative RT, we had to estimate the total number. We calculated that palliative Bone Metastasis Brain Metastasis N = 746 N = 499 RT treatment would be indicated in 1576 patients, based Age (years) 62 (95%CI: 60–64) 59 (95%CI: 56–61) on the cancer incidence of 28144 cases/year [19] and Range: 20-92 Range: 20-79 assuming an RT rate (irradiated cases divided by diag- Gender: nosed cancer cases) of 28%, following VARA I criteria [17,18], and that 20% of RT treatments would be pallia- Male 63% 65% tive treatments for BM and BrM [20]. We also estimated Female 37% 35% the percentage of RT candidates per hospital. Toxicity Primary Site: data were retrospectively gathered from clinical records. Lung 31% 56% Breast 26% 20% Statistical procedures Prostate 14% Descriptive outcomes are shown as means, medians, standard deviations and confidence intervals. The chi- Digestive 9% 8% square test was used for the comparison of independent Other Urologic 6% 3% qualitative variables. Gynaecologic 2% Head and Neck 1% Results Others 11% 13% During 2007, 1242 patients underwent RT for BM Location: (n = 744) or BrM (n = 498), i.e., 13.4% (inter-hospital range, 5-26.3%) of all patients receiving RT (9310 cases) Thoracic spine 34% in the 12 hospitals in the study. These 1242 patients Pelvis 23% represented 79% of the 1576 patients with BM or BrM Lumbar spine 22% estimated to be candidates for palliative RT. The charac- Femur 9% teristics of the patients are reported in Table 1. Mean Humerus 3% age was 62 yrs in BM patients and 59 yrs in BrM Others 9% patients; the sex distribution was similar in both groups (63% male, 37% female). Radiosurgery: 3.2% Surgery: 2.4% Bone metastases (BM) Spinal cord compression 10% The primary tumour was lung, breast and prostate in ECOG 30.8, 24.6 and 14.3% of BM cases, respectively. In more 0 24% 31% than two-thirds of cases (79%), BM were in pelvis and 1 46% 40% vertebra (cervical 7.5%, dorsal 75.5% and lumbar 17%). Patients had varying degrees of medullary compression, 2 18% 21% while the Eastern Cooperative Oncology Group (ECOG) 39% 5% performance status was 0–1 in 70% of the patients at the 43% 3% start of RT. Patients lived at a mean distance of 36 Km (95% CI 27–44) from the hospital. The mean delay from radi- H9 [Table 5]. The mean distance between residence and ation unit consultation to RT initiation was 13 days hospital was significantly higher in two hospitals (H5 (95% CI 10–15); this delay was 3 days for patients with and H8) than in the rest, and significantly longer delays spinal cord injury, and it was ≤ 7 days in 45% of all BM before RT were found in two hospitals (H5 and H10). patients [Tables 2, 3]. RT was an outpatient treatment in The mean total RT dose was 22.3 Gy (range 5-44 Gy) 73% of these patients; 53% of treatments were on a and the median was 30 Gy. The regimen was Monday or Friday. 10 × 300cGy in 32% of cases, 5 × 400 cGy in 27% and Computed tomography (CT)-based planning was per- 1 × 800 cGy in 25% [Table 4]. formed before RT in 88% of cases. The megavoltage There were significant (p < 0.0005) inter-hospital dif- machine was a Co60 unit in 42.9% of cases. Grade 2–3 ferences in the regimens prescribed for these patients toxicity was observed in 13% of patients [Table 4]. [Table 6]: 10 × 300cGy was used by four hospitals (H2, A mean of 8% of all RT treatments were for BM, with H3, H4, H6 and H12), 5 × 400 by two hospitals (H1 and significant (p < 0.005) inter-hospital differences in this H10) and 1 × 800cGy by the other three hospitals (H5, percentage, which ranged from 2.8% in H1 to 16.3% in H7 and H11). Expósito et al. Radiation Oncology 2012, 7:131 Page 4 of 7 http://www.ro-journal.com/content/7/1/131 Table 2 Distance to RT unit and delays Table 4 Treatment features Bone Metastasis Brain Metastasis Bone M Brain M Distance (Km) Doses (Gy) Range 0–365 0– 46 Range (5–44) (18–32) Mean (95%CI) 36 (27–44) 28 (22–35) Mean (95%CI) 22 (21–24) 23 (21–24) Median 21 22 Median 30 20 Delays (days) Dose fraction: Range 0– 50 0–67 10 × 300 cGy 32% 58% Mean (95%CI) 13 (10–15) 14 (12–17) 5 × 400 cGy 27% 20% Median 8 10 1 × 800 cGy 25% 3% Delays (%) 15 × 200 cGy 2% 19% < 7 days 65% 45% 3 × 600 cGy 1% >7 days 35% 55% Others 13% In-patients (%) CT planning: No 73% 56% Yes 88% 79% Yes 27% 44% No 12% 21% Energy: Co60 43% 48% Brain Metastases (BrM) The primary tumour was in the lung (56%), breast (20%) LA 6 Mv 13% 1% or digestive system (8%). Performance status was ECOG LA≥ 15 Mv 44% 51% 0–1 in 71% of BrM patients. These patients lived at a Toxicity grade 2-3 13% 15% mean distance of 28.5 Km (95% CI 22–35) [Tables 1,2]. The mean delay from first consultation to RT was 14.3 days (95% CI 11.5-17.19 d), and it was ≤7 days in 45% of significant (p < 0.005) inter-hospital differences in this cases [Table 3]. RT was an outpatient treatment in 56% percentage, which ranged from 2.6% in H1 to 10.9% in of cases. Stereotactic radiosurgery was carried out in 16 H2 [Table 5]. Again, the mean distance between resi- patients (3.2%) and surgery in 12 (2.4%). dence and hospital was significantly longer in H5 and CT-based planning was performed in 79% of cases. A H8 and the delay to RT initiation was significantly mean of 5.34% of all RT treatments were for BrM, with Table 5 Comparison of hospitals: irradiation rate Table 3 Comparison of hospitals: delay from radiation H RTcases RT BM(*) RT BrM(*) RT BM + BrM unit consultation to radiotherapy initiation 1 458 2.8% 2.6% 5.4% H D BM (TD) D BrM (TD) 1 8.63 (6.12) 7 (11.68) 2 128 13.2% 10.9% 24.1% 2 11.45 (6.92) 7.45 (5.47) 3 1081 6.8% 6.2% 13% 3 9.15 (13.35) 9.90 (13.12) 4 1111 8.5% 3.8% 12.3% 4 9.16 (11.73) 13 (7.41) 5 827 6.2% 4.2% 10.4% 5 13,10 (16.81) 20.36 (10.99) 6 430 8.4% 7.9% 16.2% 6- - 7 634 14% 4.7% 23.6% 7 10.21 (11.48) 4.81 (4.19) 8 541 4.9% 6% 10.9% 8 8.23 (18.10) 4.44 (6.45) 9 698 16.3% 10% 26.3% 9 6.02 (6.41) 4.93 (4.49) 10 999 6.45% 4.2% 10.6% 10 13.15 (20.87) 6.85 (16.58) 11 1647 7.6% 5.2% 13% 11 3.70 (8.83) 5.88 (11.60) 12 765 4.8% 4.2% 5% 12 2.55 (9.89) 6.60 (20.97) T 9319 8% 5.4% 13.4% T 8.27 (12.55) 7.93 (11.91) Mean 14.6% H = Hospital. (*) Statistical significance: p < 0.005. D BM = mean delay (days) from RT unit consultation to RT initiation for Bone M. H = Hospital. RT = Radiotherapy. BM = Bone Metastases. BrM = Brain metastases. D BrM = mean delay (days) from RT unit consultation to RT initiation for BrM. RT BM = percentage of cases treated by RT for BM. TD = typical deviation. RT BrM = percentage of cases treated by RT for BrM. Expósito et al. Radiation Oncology 2012, 7:131 Page 5 of 7 http://www.ro-journal.com/content/7/1/131 Table 6 RT schemes used in Bone Metastases by hospital* and 10-20% of relapsed patients are suitable candidates H1 × 800cGy 5 × 400 cGy 10×300cGy Others Total for palliative RT [21,22]. Studies on variations in medical practice are valuable 18 5 13 to assess the quality of care and clinical practice [23] but 61.5% 38.5% few have been published in the field of oncology. They 2 2 14 1 17 are generally used to compare treatments among geo- 11.8% 82.3% 5.9% graphical areas [24,25] or to survey medical opinions 3 12 8 45 9 74 on specific treatment options for hypothetical clinical 16.2% 10.8% 60.8% 12.2% scenarios [15,26], and both types of study have revealed a substantial variation in cancer care. A high variability 4 3 12 63 16 94 in cancer treatment outcomes has also been highlighted 3.2% 12.8% 67% 17% in reports from the EUROCARE programme [27]. 536 14 2 52 Limitations of this study include the relatively short 69.3% 26.9% 3.8% time period considered and the sources of information, 62 6 24 4 36 with some missing data (see Tables), although the fact 5.6% 16.7% 66.7% 11% that data were gathered from a direct review of clinical records and treatment sheets is a study strength. Finally, 757 20 7 6 90 it was necessary to estimate the number of potential 63.3% 22.2% 7.8% 6.7% 8 1 5 1 20 27 Table 7 RT schemes used in Brain Metastases by hospital* 3.7% 18.5% 3.7% 74.1% H3 × 600cGy 5 × 400 cGy 10 × 300cGy Others Total 9 16 36 8 54 114 13 8 1 12 14% 31.6% 7% 47.4% 25% 66.7% 8.3% 10 9 31 20 4 64 213 1 14 14.1% 48.4% 31.3% 6.3% 92.9% 7.1% 11 44 46 26 10 126 358 9 1 68 34.9% 36.6% 20.6% 7.9% 85.3% 13.2% 1.5% 12 4 8 25 37 41 2 38 1 42 10.8% 21.6% 67.6% 2.4% 4.7% 90.5% 2.4% T 184 196 240 124 744 535 35 24.7% 26.3% 32.3% 16.7% 100% * Statistical significance: p < 0.0005. 628 6 34 longer in H5 and H4. There were significant (p < 0.001) 82% 18% interhospital differences in the regimens prescribed for 724 1 5 30 these patients [Table 7], with 10 × 300cGy being used by 80% 3.3% 16.7% seven hospitals (H1, H2, H4, H5, H6, H11 and H12) and 3 × 600 cGy by two (H3 and H7). 822 10 1 33 The mean total RT dose was 22.9 (range 21–24) and 66.7% 30.3% 3% the median was 20 Gy. The schedule was 10 × 300 cGy 910 53 5 1 69 in 49% of cases and 5 × 400cGy in 28% [Table 4]. 14.5% 76.8% 7.3% 1.4% The distance from residence to hospital was not asso- 10 41 1 42 ciated with the treatment rate or the delay to RT in ei- 97.6% 2.4% ther group of patients. 11 16 63 8 87 Discussion 18.4% 72.4% 9.2% Novel therapeutic approaches have improved the sur- 12 32 32 vival of cancer patients, including some with metastases 100% from solid tumours, thereby increasing the demand for T 93 138 246 21 498 palliative RT. The effectiveness of external RT has been 18.7% 27.7% 49.4% 4.2% widely demonstrated [4,20], and it has been estimated that around 50% of patients with newly diagnosed cancer * Statistical significance: p < 0.001. Expósito et al. Radiation Oncology 2012, 7:131 Page 6 of 7 http://www.ro-journal.com/content/7/1/131 candidates for palliative RT in each hospital, although intellectual content, final approval for publication. JJ: substantial contributions to conception and design of the study, acquisition and analysis our estimation was slightly lower than that reported by of data. EA: substantial contributions to conception and design of the study, Nieder et al. [5]. acquisition and analysis of data. IT: interpretation of data, contribution to The distribution of clinical variables and tumour sites draft the manuscript, critically revision for important intellectual content. All authors read and approved the final manuscript. in the cancer patients in these hospitals was similar to previous international reports [28]. Although the hospi- Acknowledgments tals in this study were all referral centres for RT, the The VARA II project was funded by Health Andalusia Authority grant PI-0266/ 2007 (BOJA n 14, 21 January 2008). mean distance from the patient’s home to the RT unit was shorter than in other studies [29]. If the results Author details for two of the hospitals (H5 and H10) are excluded, the Radiation Oncology Department, Virgen de las Nieves University Hospital, Avd Fuerzas Armadas 4, Granada 18014, Spain. Institute of Oncology Cartuja, median delay from first consultation to RT initiation Sevilla, Spain. Radiation Oncology Department, Puerta del Mar University was 13 days, which can be considered acceptable [8,20]. Hospital, Cádiz, Spain. Treatment schedules varied widely among centres Received: 1 February 2012 Accepted: 20 July 2012 [Tables 6,7], consistent with previous reports in different Published: 3 August 2012 countries [12-16]. The observed treatment rate was slightly lower than References 1. Rubin P: Clinical Oncoly.In A multidisciplinary approach for physicians and the expected rate but was higher than our group found students. 8th edition. Philadelphia: WB Saunders Co; 2001. for other cancer sites [9,18], indicating a greater confi- 2. Coia LR, Owen JB, Maher EJ, Hanks GE: Factors affecting treatment dence about the use of RT with palliative rather than patterns of radiation oncologists in the United States in the palliative treatment of cancer. Clin Oncol (R Coll Radiol) 1992, 4(1):6–10. radical or curative intent. RT with palliative intent repre- 3. Board of the Faculty of Clinical Oncology: Equipment, workload and staffing sented 14% of all patients undergoing RT, but the hospi- for radiotherapy in the UK 1997–2002. London: The Royal College of tals varied widely and significantly in the selection of Radiologists; 2003. 4. Halpering EC, Perez CA, Brady LW: Principles and Practice of Radiation treatment regimen. The reasons for this variation are Oncology. 5th edition. Philadelphia: Lippincott; 2008. not clear and warrant further investigation, although dif- 5. Nieder C, Pawinski A, Haukland E, Dokmo R, Phillipi I, Dalhaug A: Estimating ferences in case mix or in the number of patients receiv- need for palliative external beam radiotherapy in adult cancer patients. Int J Radiat Oncol Biol Phys 2010, 76(1):207–211. ing adjuvant or radical RT may play a role. 6. Tsuji S, Wara WM: Palliation and benign Conditions.In Hansen EK and According to our findings, the same type of clinical Roch III M. Handbook of Evidence-Based Radiation Oncology. 2nd edition. situation is treated with very different doses (total and New York: Springer Verlag; 2010. 7. Roos DE: Continuing reluctance to use single fractions of radiotherapy per fraction) in our region. This is a frequent observa- for metastatic bone pain: an Australian and New Zealand practice survey tion in BM therapy [12,30] and appears to be more and literature review. Radiother Oncol 2000, 56(3):315–322. related to the clinical care pattern established in RT 8. Chow E, Danjoux C, Wong R, Szumacher E, Franssen E, Fung K, Finkelstein J, Andersson L, Connolly R: Palliation of bone metastases: a survey of units rather than to effectiveness or clinical criteria. In patterns of practice among Canadian radiation oncologists. Radiother BM patients, the frequency of the standard 1x800 cGy Oncol 2000, 56(3):305–314. scheme, which is supported by well-conducted studies 9. Wennberg JE, Gittelsohn AM: Small area variations in health care delivery. A population-based health information system can guide planning and [16,31-33], was strikingly low (25%). regulatory decision-making. Science 1973, 18:1102–1108. In conclusion, the rate of palliative RT use for BM and 10. Wennberg JE, Gittelsohn AM: Variations in medical care among small BrM in these hospitals was close to published reports, areas. Sci. Am 1982, 264:100–111. unlike the use of RT for other clinical purposes. More- 11. Mackillop WJ, Dixon P, Zhou Y, Ago CT, Ege G, Hodson DI, Kotalik JF, Lochrin C, Paszat L, Harris D: Variation in the management and over, the delay before RT initiation was relatively low, outcome of non-small cell lung cancer in Ontario. Radiother Oncol 1994, and the overall rate of RT utilization appears to have 32(2):106–115. been adequate. However, there was a variation in treat- 12. Fairchild A, Barnes E, Ghosh S, Ben-Josef E, Roos D, Hartsell W, Holt T, Wu J, Janjan N, Chow E: International patterns of practice in palliative ment schedules among hospitals that requires further radiotherapy for painful bone metastases: evidence-based practice? Int J investigation and suggests a need to develop protocols Radiat Oncol Biol Phys 2009, 75(5):1501––10. Epub May 21. and training programmes to standardize and improve 13. Bradley NM, Husted J, Sey MS, Husain AF, Sinclair E, Harris K, Chow E: Review of patterns of practice and patients' preferences in the the care of these patients in our setting. treatment of bone metastases with palliative radiotherapy. Support Care Cance 2007, 15(4)):373–385. Epub 2006 Nov 9. Abbreviations 14. Sharma V, Gaye PM, Wahab SA, Ndlovu N, Ngoma T, Vanderpuye V, RT: Radiotherapy; BM: Bone metastases; BrM: Brain metastases; Sowunmi A, Kigula-Mugambe J, Jeremic B: Patterns of practice of VARA: Variability and Appropriateness of Radiotherapy in Andalusia; palliative radiotherapy in Africa, Part 1: Bone and brain metastases. Int J H: Hospital; CT: Computed Tomography. Radiat Oncol Biol Phys. 2008, 70(4):1195–201. Epub 2007 Oct 29. 15. Gupta T, Sarin R: Palliative radiation therapy for painful vertebral Competing interests metastases: a practice survey. Cancer 2004, 101(12):2892–2896. The authors declare that they have no competing interests. 16. van der Linden Y, Roos D, Lutz S, Fairchild A: International variations in radiotherapy fractionation for bone metastases: geographic Authors’ contributions borders define practice patterns? Clin Oncol (R Coll Radiol) 2009, JE: substantial contributions to conception and design of the study, 21(9):655–658. interpretation of data, draft the manuscript, critically revision for important Expósito et al. Radiation Oncology 2012, 7:131 Page 7 of 7 http://www.ro-journal.com/content/7/1/131 17. Expósito J, Jaén J, Alonso E, Cabrera P: Variabilidad en los tratamientos con radioterapia externa. Estudio de los hospitales públicos de Andalucía. Var Práct Méd Sist Nac Salud 2009, 3(2):236–240. http://www. google.es/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&ved= 0CFEQFjAB&url=http%3A%2F%2Fwww.atlasvpm.org%2Favpm%2FnodoUser. navegar.do%3FidObjeto%3D165&ei=F9T5T5G4IoGH0AXT5LyQCQ&usg= AFQjCNFKBfv0m96cneqidkGaoErUQ65V6Q. 18. Jaén J, Alonso E, Expósito J, de las Peñas MD, Cabrera P: Evidence-based estimation and radiotherapy utilisation rate in Andalusia. Clin Traslat Oncol 2007, 9:789–796. 19. Situación del Cáncer en España: Instituto de Salud Carlos III. Madrid: Ministerio de Sanidad y Consumo; 2005. 20. Lawton PA, Maher EJ, In association with ESTRO: Treatment strategies for advanced metastatic cancer in Europe. Radiother Oncol 1991, 22:1–6. 21. Bentzen SM, Heeren G, Cottier B, Slotman B, Glimelius B, Lievens Y, van den Bogaert W: Towards evidence-based guideline for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiother Oncol 2005, 75:355–365. 22. Delaney G, Jacob S, Featherstone C, Barton M: The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer 2005, 104:1129–1137. 23. Weenberg J: The quality of medical care in the United States: A report on the Medicare Programme. Chicago: AHA Press; 1999. 24. Burnet NG, Benson RJ, William MV, Peacock JH: Improving cancer outcomes trougth radiotherapy: Lack of UK radiotherapy resources prejudices cancer outcomes. BMJ 2000, 320:198–199. 25. Mackillop WJ, Ward GK, Sullivan BO: The use of expert surrogates to evaluate clinical trials in non-small cell lung cancer. Br.J Cancer 1986, 54:661–667. 26. Walsh GL, Winn RJ: Baseline institutional compliance with NCCN guidelines: non-small-cell lung cancer. Oncology 1997, 11:161–170. 27. Berrino F, Verdecchia A, Lutz JM, Lombardo C, Micheli A, Capocaccia R: Comparative cancer survival information in Europe. Eur J Cancer 2009, 45:901–908. 28. Mueller RP, Soffietti R, Abacioglu MU, Villa S, Fauchon F, Baumert BG, Fariselli L, Tzuk-Shina T, Collette L, Kocher M: Adjuvant Whole Brain Radiotherapy Versus Observation After Radiosurgical or Surgical Resection for 1–3 Cerebral Metastases: Results of the OERTC 22952–26001 Study [abstract]. J Clin Oncol 2009, 27(s15). 29. Tyldesley S, McGahan C: Utilisation of radiotherapy in rural and urban areas in British Columbia compared with evidence-based estimates of radiotherapy needs for patients with breast, prostate and lung cancer. Clin Oncol (R Coll Radiol) 2010, 22:526–532. 30. Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, Howell D, Konski A, Kachnic L, Lo S, Sahgal A, Silverman L, von Gunten C, Mendel E, Vassil A, Bruner DW, Hartsell W: Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline. Int J Radiat Oncol Biol Phys 2011, 79:965–976. 31. Wu JS, Wong R, Johnston M, Bezjak A, Whelan T: Meta-analysis of dose- fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 2003, 55(3):594–605. 32. Chow E, Harris K, Fan G, Tsao M, Sze WM: Palliative radiotherapy trials for bone metastases: a systematic review. J Clin Oncol 2007, 25:1423–1436. 33. Hartsell WF, Konski AA, Lo SS, Hayman JA: Single fraction radiotherapy for bone metastases: clinically effective, time efficient, cost conscious and still underutilized in the United States? Clin Oncol (R Coll Radiol) 2009, 21(9):652–654. Submit your next manuscript to BioMed Central doi:10.1186/1748-717X-7-131 and take full advantage of: Cite this article as: Expósito et al.: Use of palliative radiotherapy in brain and bone metastases (VARA II study). Radiation Oncology 2012 7:131. • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Radiation Oncology Springer Journals

Use of palliative radiotherapy in brain and bone metastases (VARA II study)

Loading next page...
 
/lp/springer-journals/use-of-palliative-radiotherapy-in-brain-and-bone-metastases-vara-ii-hg13hH3uxy

References (39)

Publisher
Springer Journals
Copyright
Copyright © 2012 by Expósito et al.; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Oncology; Radiotherapy
eISSN
1748-717X
DOI
10.1186/1748-717X-7-131
pmid
22863023
Publisher site
See Article on Publisher Site

Abstract

Introduction: Metastases are detected in 20% of patients with solid tumours at diagnosis and a further 30% after diagnosis. Radiation therapy (RT) has proven effective in bone (BM) and brain (BrM) metastases. The objective of this study was to analyze the variability of RT utilization rates in clinical practice and the accessibility to medical technology in our region. Patients and methods: We reviewed the clinical records and RT treatment sheets of all patients undergoing RT for BM and/or BrM during 2007 in the 12 public hospitals in an autonomous region of Spain. Data were gathered on hospital type, patient type and RT treatment characteristics. Calculation of the rate of RT use was based on the cancer incidence and the number of RT treatments for BM, BrM and all cancer sites. Results: Out of the 9319 patients undergoing RT during 2007 for cancer at any site, 1242 (13.3%; inter-hospital range, 26.3%) received RT for BM (n = 744) or BrM (n = 498). These 1242 patients represented 79% of all RT treatments with palliative intent, and the most frequent primary tumours were in lung, breast, prostate or digestive system. No significant difference between BM and BrM groups were observed in: mean age (62 vs. 59 yrs, respectively); gender (approximately 64% male and 36% female in both); performance status (ECOG 0–1 in 70 vs. 71%); or mean distance from hospital (36 vs. 28.6 km) or time from consultation to RT treatment (13 vs. 14.3 days). RT regimens differed among hospitals and between patient groups: 10 × 300 cGy, 5 × 400 cGy and 1x800cGy were applied in 32, 27 and 25%, respectively, of BM patients, whereas 10 × 300cGy was used in 49% of BrM patients. Conclusions: Palliative RT use in BM and BrM is high and close to the expected rate, unlike the global rate of RT application for all cancers in our setting. Differences in RT schedules among hospitals may reflect variability in clinical practice among the medical teams. Keywords: Palliative radiation therapy, Variability, Bone metastases, Brain metastases Introduction and a further 30% develop metastases at some time after Cancer remains a major health and social problem. the diagnosis [3]. Treatment for patients with metastases Therapeutic advances over the past decade have pro- is usually with palliative intent and focuses on the con- duced important improvements in cancer control and in trol of symptoms and the maximization of symptom-free the survival of cancer patients, and a better management time. Metastases are most frequently localized in bone, brain, lung and liver and usually derive from primary of their symptoms has enhanced their quality of life [1]. tumours in breast, prostate, colon/rectum and lung, i.e., Progress has been made in surgery, chemotherapy and the most frequent solid tumours [1]. radiation therapy (RT) and in their greater coordination As in primary tumours, the best outcomes in metastatic in a multidisciplinary approach [2]. cancer are obtained by adopting a multidisciplinary It is estimated that around 20% of patients with solid approach. The use of RT in this setting is supported by tumours are diagnosed after the spread of the disease considerable and robust evidence. It is considered one of the most effective and cost-effective treatments in patients * Correspondence: jose.exposito.sspa@juntadeandalucia.es with bone (BM) or brain (BrM) metastases [4], and pal- Radiation Oncology Department, Virgen de las Nieves University Hospital, liative RT represents around 10-20% of the total work- Avd Fuerzas Armadas 4, Granada 18014, Spain load in a typical radiotherapy unit [5]. Hypofractionated Full list of author information is available at the end of the article © 2012 Expósito et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Expósito et al. Radiation Oncology 2012, 7:131 Page 2 of 7 http://www.ro-journal.com/content/7/1/131 regimens of short duration are generally prescribed for Patients and methods these patients, although a wide range of regimens and This retrospective longitudinal study included all public combinations has been applied [6,7]. Comparative data hospitals in Andalusia (Spain) equipped with RT devices on RT utilization rates across different hospitals are of (n = 12, H1-H12); the study period was from January 1 interest to indicate the access of patients to this technol- to December 31 2007; data were gathered on all patients ogy, its appropriateness and the variability in medical treated with external RT for BM or BrM, including practice [8]. There have been reports of variations in details of all palliative RT treatments. Patients were the use of RT for different tumours [9-11] and in the identified from the clinical management computer W W dose schedules selected for BM and BrM among differ- system linked to the RT equipment (Varis , lantis or ent centres [12-16]. In our region, a previous study found Impac Departmental networks) and from the hospitals’ a suboptimal RT utilization rate and significant variabil- admission records. The same sources were used to ity in the use of RT differences among hospitals [17,18]. gather data on all patients irradiated in any cancer This finding prompted the present investigation into the site during the study period. Clinical records and RT use of RT in BM and BrM, two well-established indica- sheets were reviewed by specifically trained researchers. tions for this treatment. When errors or incongruous results were detected, a Andalusia has a surface area of 87597Km and 7.8 million second review was performed by another member of inhabitants; around half (45.6%) of the population lives the research team. within a 20 km radius around the eight cities in the re- Data were gathered on the type of hospital and RT gion. The regional public health system provides unit and on the demographic and clinical characteristics universal free coverage, while 10% of the total care is and RT treatments of the patients. Study variables delivered in private healthcare facilities. Figure 1 shows included characteristics of the hospital (province), patient the distribution of RT departments in the region. (age, gender, type [brain/bone], performance status with This study focuses on the RT utilization rate and the Eastern Cooperative Oncology Group [ECOG] scale or patterns of palliative RT application in patients with BM Karnofsky scale and primary tumour site), and treatment and BrM. It is part of a broader investigation (Variability (medical indication: total doses, fractions, delay after and Appropriateness of Radiotherapy in Andalusia decision, radiosurgery/surgery in brain metastasis, and [VARA] projects I and II) into the quality of RT deliv- adverse effects [acute grade 2-3 toxicity]). The distance ered in 12 public hospitals in the Andalusian public from RT facilities was based on the area code directory. health system [17]. Because of the difficulty of identifying all patients in Figure 1 Location of radiotherapy departments in Andalusia. TC – Torrecárdenas Hospital (Almería). VN - Virgen de las Nieves University Hospital (Granada). SC - San Cecilio University Hospital (Granada). J - Jaén Hospital (Jaén). RS - Reina Sofía University Hospital (Córdoba). CH - Carlos Haya University Hospital (Málaga). VV - Virgen de la Victoria University Hospital (Málaga). PE - Punta de Europa Hospital (Algeciras, Cádiz). PM - Puerta del Mar University Hospital (Cádiz). VM - Virgen del Rocío University Hospital (Sevilla). VR - Virgen de la Macarena University Hospital (Sevilla). JRJ - Juan Ramón Jiménez Hospital (Huelva). Expósito et al. Radiation Oncology 2012, 7:131 Page 3 of 7 http://www.ro-journal.com/content/7/1/131 Table 1 Characteristics of patients the region with indications for palliative RT, we had to estimate the total number. We calculated that palliative Bone Metastasis Brain Metastasis N = 746 N = 499 RT treatment would be indicated in 1576 patients, based Age (years) 62 (95%CI: 60–64) 59 (95%CI: 56–61) on the cancer incidence of 28144 cases/year [19] and Range: 20-92 Range: 20-79 assuming an RT rate (irradiated cases divided by diag- Gender: nosed cancer cases) of 28%, following VARA I criteria [17,18], and that 20% of RT treatments would be pallia- Male 63% 65% tive treatments for BM and BrM [20]. We also estimated Female 37% 35% the percentage of RT candidates per hospital. Toxicity Primary Site: data were retrospectively gathered from clinical records. Lung 31% 56% Breast 26% 20% Statistical procedures Prostate 14% Descriptive outcomes are shown as means, medians, standard deviations and confidence intervals. The chi- Digestive 9% 8% square test was used for the comparison of independent Other Urologic 6% 3% qualitative variables. Gynaecologic 2% Head and Neck 1% Results Others 11% 13% During 2007, 1242 patients underwent RT for BM Location: (n = 744) or BrM (n = 498), i.e., 13.4% (inter-hospital range, 5-26.3%) of all patients receiving RT (9310 cases) Thoracic spine 34% in the 12 hospitals in the study. These 1242 patients Pelvis 23% represented 79% of the 1576 patients with BM or BrM Lumbar spine 22% estimated to be candidates for palliative RT. The charac- Femur 9% teristics of the patients are reported in Table 1. Mean Humerus 3% age was 62 yrs in BM patients and 59 yrs in BrM Others 9% patients; the sex distribution was similar in both groups (63% male, 37% female). Radiosurgery: 3.2% Surgery: 2.4% Bone metastases (BM) Spinal cord compression 10% The primary tumour was lung, breast and prostate in ECOG 30.8, 24.6 and 14.3% of BM cases, respectively. In more 0 24% 31% than two-thirds of cases (79%), BM were in pelvis and 1 46% 40% vertebra (cervical 7.5%, dorsal 75.5% and lumbar 17%). Patients had varying degrees of medullary compression, 2 18% 21% while the Eastern Cooperative Oncology Group (ECOG) 39% 5% performance status was 0–1 in 70% of the patients at the 43% 3% start of RT. Patients lived at a mean distance of 36 Km (95% CI 27–44) from the hospital. The mean delay from radi- H9 [Table 5]. The mean distance between residence and ation unit consultation to RT initiation was 13 days hospital was significantly higher in two hospitals (H5 (95% CI 10–15); this delay was 3 days for patients with and H8) than in the rest, and significantly longer delays spinal cord injury, and it was ≤ 7 days in 45% of all BM before RT were found in two hospitals (H5 and H10). patients [Tables 2, 3]. RT was an outpatient treatment in The mean total RT dose was 22.3 Gy (range 5-44 Gy) 73% of these patients; 53% of treatments were on a and the median was 30 Gy. The regimen was Monday or Friday. 10 × 300cGy in 32% of cases, 5 × 400 cGy in 27% and Computed tomography (CT)-based planning was per- 1 × 800 cGy in 25% [Table 4]. formed before RT in 88% of cases. The megavoltage There were significant (p < 0.0005) inter-hospital dif- machine was a Co60 unit in 42.9% of cases. Grade 2–3 ferences in the regimens prescribed for these patients toxicity was observed in 13% of patients [Table 4]. [Table 6]: 10 × 300cGy was used by four hospitals (H2, A mean of 8% of all RT treatments were for BM, with H3, H4, H6 and H12), 5 × 400 by two hospitals (H1 and significant (p < 0.005) inter-hospital differences in this H10) and 1 × 800cGy by the other three hospitals (H5, percentage, which ranged from 2.8% in H1 to 16.3% in H7 and H11). Expósito et al. Radiation Oncology 2012, 7:131 Page 4 of 7 http://www.ro-journal.com/content/7/1/131 Table 2 Distance to RT unit and delays Table 4 Treatment features Bone Metastasis Brain Metastasis Bone M Brain M Distance (Km) Doses (Gy) Range 0–365 0– 46 Range (5–44) (18–32) Mean (95%CI) 36 (27–44) 28 (22–35) Mean (95%CI) 22 (21–24) 23 (21–24) Median 21 22 Median 30 20 Delays (days) Dose fraction: Range 0– 50 0–67 10 × 300 cGy 32% 58% Mean (95%CI) 13 (10–15) 14 (12–17) 5 × 400 cGy 27% 20% Median 8 10 1 × 800 cGy 25% 3% Delays (%) 15 × 200 cGy 2% 19% < 7 days 65% 45% 3 × 600 cGy 1% >7 days 35% 55% Others 13% In-patients (%) CT planning: No 73% 56% Yes 88% 79% Yes 27% 44% No 12% 21% Energy: Co60 43% 48% Brain Metastases (BrM) The primary tumour was in the lung (56%), breast (20%) LA 6 Mv 13% 1% or digestive system (8%). Performance status was ECOG LA≥ 15 Mv 44% 51% 0–1 in 71% of BrM patients. These patients lived at a Toxicity grade 2-3 13% 15% mean distance of 28.5 Km (95% CI 22–35) [Tables 1,2]. The mean delay from first consultation to RT was 14.3 days (95% CI 11.5-17.19 d), and it was ≤7 days in 45% of significant (p < 0.005) inter-hospital differences in this cases [Table 3]. RT was an outpatient treatment in 56% percentage, which ranged from 2.6% in H1 to 10.9% in of cases. Stereotactic radiosurgery was carried out in 16 H2 [Table 5]. Again, the mean distance between resi- patients (3.2%) and surgery in 12 (2.4%). dence and hospital was significantly longer in H5 and CT-based planning was performed in 79% of cases. A H8 and the delay to RT initiation was significantly mean of 5.34% of all RT treatments were for BrM, with Table 5 Comparison of hospitals: irradiation rate Table 3 Comparison of hospitals: delay from radiation H RTcases RT BM(*) RT BrM(*) RT BM + BrM unit consultation to radiotherapy initiation 1 458 2.8% 2.6% 5.4% H D BM (TD) D BrM (TD) 1 8.63 (6.12) 7 (11.68) 2 128 13.2% 10.9% 24.1% 2 11.45 (6.92) 7.45 (5.47) 3 1081 6.8% 6.2% 13% 3 9.15 (13.35) 9.90 (13.12) 4 1111 8.5% 3.8% 12.3% 4 9.16 (11.73) 13 (7.41) 5 827 6.2% 4.2% 10.4% 5 13,10 (16.81) 20.36 (10.99) 6 430 8.4% 7.9% 16.2% 6- - 7 634 14% 4.7% 23.6% 7 10.21 (11.48) 4.81 (4.19) 8 541 4.9% 6% 10.9% 8 8.23 (18.10) 4.44 (6.45) 9 698 16.3% 10% 26.3% 9 6.02 (6.41) 4.93 (4.49) 10 999 6.45% 4.2% 10.6% 10 13.15 (20.87) 6.85 (16.58) 11 1647 7.6% 5.2% 13% 11 3.70 (8.83) 5.88 (11.60) 12 765 4.8% 4.2% 5% 12 2.55 (9.89) 6.60 (20.97) T 9319 8% 5.4% 13.4% T 8.27 (12.55) 7.93 (11.91) Mean 14.6% H = Hospital. (*) Statistical significance: p < 0.005. D BM = mean delay (days) from RT unit consultation to RT initiation for Bone M. H = Hospital. RT = Radiotherapy. BM = Bone Metastases. BrM = Brain metastases. D BrM = mean delay (days) from RT unit consultation to RT initiation for BrM. RT BM = percentage of cases treated by RT for BM. TD = typical deviation. RT BrM = percentage of cases treated by RT for BrM. Expósito et al. Radiation Oncology 2012, 7:131 Page 5 of 7 http://www.ro-journal.com/content/7/1/131 Table 6 RT schemes used in Bone Metastases by hospital* and 10-20% of relapsed patients are suitable candidates H1 × 800cGy 5 × 400 cGy 10×300cGy Others Total for palliative RT [21,22]. Studies on variations in medical practice are valuable 18 5 13 to assess the quality of care and clinical practice [23] but 61.5% 38.5% few have been published in the field of oncology. They 2 2 14 1 17 are generally used to compare treatments among geo- 11.8% 82.3% 5.9% graphical areas [24,25] or to survey medical opinions 3 12 8 45 9 74 on specific treatment options for hypothetical clinical 16.2% 10.8% 60.8% 12.2% scenarios [15,26], and both types of study have revealed a substantial variation in cancer care. A high variability 4 3 12 63 16 94 in cancer treatment outcomes has also been highlighted 3.2% 12.8% 67% 17% in reports from the EUROCARE programme [27]. 536 14 2 52 Limitations of this study include the relatively short 69.3% 26.9% 3.8% time period considered and the sources of information, 62 6 24 4 36 with some missing data (see Tables), although the fact 5.6% 16.7% 66.7% 11% that data were gathered from a direct review of clinical records and treatment sheets is a study strength. Finally, 757 20 7 6 90 it was necessary to estimate the number of potential 63.3% 22.2% 7.8% 6.7% 8 1 5 1 20 27 Table 7 RT schemes used in Brain Metastases by hospital* 3.7% 18.5% 3.7% 74.1% H3 × 600cGy 5 × 400 cGy 10 × 300cGy Others Total 9 16 36 8 54 114 13 8 1 12 14% 31.6% 7% 47.4% 25% 66.7% 8.3% 10 9 31 20 4 64 213 1 14 14.1% 48.4% 31.3% 6.3% 92.9% 7.1% 11 44 46 26 10 126 358 9 1 68 34.9% 36.6% 20.6% 7.9% 85.3% 13.2% 1.5% 12 4 8 25 37 41 2 38 1 42 10.8% 21.6% 67.6% 2.4% 4.7% 90.5% 2.4% T 184 196 240 124 744 535 35 24.7% 26.3% 32.3% 16.7% 100% * Statistical significance: p < 0.0005. 628 6 34 longer in H5 and H4. There were significant (p < 0.001) 82% 18% interhospital differences in the regimens prescribed for 724 1 5 30 these patients [Table 7], with 10 × 300cGy being used by 80% 3.3% 16.7% seven hospitals (H1, H2, H4, H5, H6, H11 and H12) and 3 × 600 cGy by two (H3 and H7). 822 10 1 33 The mean total RT dose was 22.9 (range 21–24) and 66.7% 30.3% 3% the median was 20 Gy. The schedule was 10 × 300 cGy 910 53 5 1 69 in 49% of cases and 5 × 400cGy in 28% [Table 4]. 14.5% 76.8% 7.3% 1.4% The distance from residence to hospital was not asso- 10 41 1 42 ciated with the treatment rate or the delay to RT in ei- 97.6% 2.4% ther group of patients. 11 16 63 8 87 Discussion 18.4% 72.4% 9.2% Novel therapeutic approaches have improved the sur- 12 32 32 vival of cancer patients, including some with metastases 100% from solid tumours, thereby increasing the demand for T 93 138 246 21 498 palliative RT. The effectiveness of external RT has been 18.7% 27.7% 49.4% 4.2% widely demonstrated [4,20], and it has been estimated that around 50% of patients with newly diagnosed cancer * Statistical significance: p < 0.001. Expósito et al. Radiation Oncology 2012, 7:131 Page 6 of 7 http://www.ro-journal.com/content/7/1/131 candidates for palliative RT in each hospital, although intellectual content, final approval for publication. JJ: substantial contributions to conception and design of the study, acquisition and analysis our estimation was slightly lower than that reported by of data. EA: substantial contributions to conception and design of the study, Nieder et al. [5]. acquisition and analysis of data. IT: interpretation of data, contribution to The distribution of clinical variables and tumour sites draft the manuscript, critically revision for important intellectual content. All authors read and approved the final manuscript. in the cancer patients in these hospitals was similar to previous international reports [28]. Although the hospi- Acknowledgments tals in this study were all referral centres for RT, the The VARA II project was funded by Health Andalusia Authority grant PI-0266/ 2007 (BOJA n 14, 21 January 2008). mean distance from the patient’s home to the RT unit was shorter than in other studies [29]. If the results Author details for two of the hospitals (H5 and H10) are excluded, the Radiation Oncology Department, Virgen de las Nieves University Hospital, Avd Fuerzas Armadas 4, Granada 18014, Spain. Institute of Oncology Cartuja, median delay from first consultation to RT initiation Sevilla, Spain. Radiation Oncology Department, Puerta del Mar University was 13 days, which can be considered acceptable [8,20]. Hospital, Cádiz, Spain. Treatment schedules varied widely among centres Received: 1 February 2012 Accepted: 20 July 2012 [Tables 6,7], consistent with previous reports in different Published: 3 August 2012 countries [12-16]. The observed treatment rate was slightly lower than References 1. Rubin P: Clinical Oncoly.In A multidisciplinary approach for physicians and the expected rate but was higher than our group found students. 8th edition. Philadelphia: WB Saunders Co; 2001. for other cancer sites [9,18], indicating a greater confi- 2. Coia LR, Owen JB, Maher EJ, Hanks GE: Factors affecting treatment dence about the use of RT with palliative rather than patterns of radiation oncologists in the United States in the palliative treatment of cancer. Clin Oncol (R Coll Radiol) 1992, 4(1):6–10. radical or curative intent. RT with palliative intent repre- 3. Board of the Faculty of Clinical Oncology: Equipment, workload and staffing sented 14% of all patients undergoing RT, but the hospi- for radiotherapy in the UK 1997–2002. London: The Royal College of tals varied widely and significantly in the selection of Radiologists; 2003. 4. Halpering EC, Perez CA, Brady LW: Principles and Practice of Radiation treatment regimen. The reasons for this variation are Oncology. 5th edition. Philadelphia: Lippincott; 2008. not clear and warrant further investigation, although dif- 5. Nieder C, Pawinski A, Haukland E, Dokmo R, Phillipi I, Dalhaug A: Estimating ferences in case mix or in the number of patients receiv- need for palliative external beam radiotherapy in adult cancer patients. Int J Radiat Oncol Biol Phys 2010, 76(1):207–211. ing adjuvant or radical RT may play a role. 6. Tsuji S, Wara WM: Palliation and benign Conditions.In Hansen EK and According to our findings, the same type of clinical Roch III M. Handbook of Evidence-Based Radiation Oncology. 2nd edition. situation is treated with very different doses (total and New York: Springer Verlag; 2010. 7. Roos DE: Continuing reluctance to use single fractions of radiotherapy per fraction) in our region. This is a frequent observa- for metastatic bone pain: an Australian and New Zealand practice survey tion in BM therapy [12,30] and appears to be more and literature review. Radiother Oncol 2000, 56(3):315–322. related to the clinical care pattern established in RT 8. Chow E, Danjoux C, Wong R, Szumacher E, Franssen E, Fung K, Finkelstein J, Andersson L, Connolly R: Palliation of bone metastases: a survey of units rather than to effectiveness or clinical criteria. In patterns of practice among Canadian radiation oncologists. Radiother BM patients, the frequency of the standard 1x800 cGy Oncol 2000, 56(3):305–314. scheme, which is supported by well-conducted studies 9. Wennberg JE, Gittelsohn AM: Small area variations in health care delivery. A population-based health information system can guide planning and [16,31-33], was strikingly low (25%). regulatory decision-making. Science 1973, 18:1102–1108. In conclusion, the rate of palliative RT use for BM and 10. Wennberg JE, Gittelsohn AM: Variations in medical care among small BrM in these hospitals was close to published reports, areas. Sci. Am 1982, 264:100–111. unlike the use of RT for other clinical purposes. More- 11. Mackillop WJ, Dixon P, Zhou Y, Ago CT, Ege G, Hodson DI, Kotalik JF, Lochrin C, Paszat L, Harris D: Variation in the management and over, the delay before RT initiation was relatively low, outcome of non-small cell lung cancer in Ontario. Radiother Oncol 1994, and the overall rate of RT utilization appears to have 32(2):106–115. been adequate. However, there was a variation in treat- 12. Fairchild A, Barnes E, Ghosh S, Ben-Josef E, Roos D, Hartsell W, Holt T, Wu J, Janjan N, Chow E: International patterns of practice in palliative ment schedules among hospitals that requires further radiotherapy for painful bone metastases: evidence-based practice? Int J investigation and suggests a need to develop protocols Radiat Oncol Biol Phys 2009, 75(5):1501––10. Epub May 21. and training programmes to standardize and improve 13. Bradley NM, Husted J, Sey MS, Husain AF, Sinclair E, Harris K, Chow E: Review of patterns of practice and patients' preferences in the the care of these patients in our setting. treatment of bone metastases with palliative radiotherapy. Support Care Cance 2007, 15(4)):373–385. Epub 2006 Nov 9. Abbreviations 14. Sharma V, Gaye PM, Wahab SA, Ndlovu N, Ngoma T, Vanderpuye V, RT: Radiotherapy; BM: Bone metastases; BrM: Brain metastases; Sowunmi A, Kigula-Mugambe J, Jeremic B: Patterns of practice of VARA: Variability and Appropriateness of Radiotherapy in Andalusia; palliative radiotherapy in Africa, Part 1: Bone and brain metastases. Int J H: Hospital; CT: Computed Tomography. Radiat Oncol Biol Phys. 2008, 70(4):1195–201. Epub 2007 Oct 29. 15. Gupta T, Sarin R: Palliative radiation therapy for painful vertebral Competing interests metastases: a practice survey. Cancer 2004, 101(12):2892–2896. The authors declare that they have no competing interests. 16. van der Linden Y, Roos D, Lutz S, Fairchild A: International variations in radiotherapy fractionation for bone metastases: geographic Authors’ contributions borders define practice patterns? Clin Oncol (R Coll Radiol) 2009, JE: substantial contributions to conception and design of the study, 21(9):655–658. interpretation of data, draft the manuscript, critically revision for important Expósito et al. Radiation Oncology 2012, 7:131 Page 7 of 7 http://www.ro-journal.com/content/7/1/131 17. Expósito J, Jaén J, Alonso E, Cabrera P: Variabilidad en los tratamientos con radioterapia externa. Estudio de los hospitales públicos de Andalucía. Var Práct Méd Sist Nac Salud 2009, 3(2):236–240. http://www. google.es/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&ved= 0CFEQFjAB&url=http%3A%2F%2Fwww.atlasvpm.org%2Favpm%2FnodoUser. navegar.do%3FidObjeto%3D165&ei=F9T5T5G4IoGH0AXT5LyQCQ&usg= AFQjCNFKBfv0m96cneqidkGaoErUQ65V6Q. 18. Jaén J, Alonso E, Expósito J, de las Peñas MD, Cabrera P: Evidence-based estimation and radiotherapy utilisation rate in Andalusia. Clin Traslat Oncol 2007, 9:789–796. 19. Situación del Cáncer en España: Instituto de Salud Carlos III. Madrid: Ministerio de Sanidad y Consumo; 2005. 20. Lawton PA, Maher EJ, In association with ESTRO: Treatment strategies for advanced metastatic cancer in Europe. Radiother Oncol 1991, 22:1–6. 21. Bentzen SM, Heeren G, Cottier B, Slotman B, Glimelius B, Lievens Y, van den Bogaert W: Towards evidence-based guideline for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiother Oncol 2005, 75:355–365. 22. Delaney G, Jacob S, Featherstone C, Barton M: The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer 2005, 104:1129–1137. 23. Weenberg J: The quality of medical care in the United States: A report on the Medicare Programme. Chicago: AHA Press; 1999. 24. Burnet NG, Benson RJ, William MV, Peacock JH: Improving cancer outcomes trougth radiotherapy: Lack of UK radiotherapy resources prejudices cancer outcomes. BMJ 2000, 320:198–199. 25. Mackillop WJ, Ward GK, Sullivan BO: The use of expert surrogates to evaluate clinical trials in non-small cell lung cancer. Br.J Cancer 1986, 54:661–667. 26. Walsh GL, Winn RJ: Baseline institutional compliance with NCCN guidelines: non-small-cell lung cancer. Oncology 1997, 11:161–170. 27. Berrino F, Verdecchia A, Lutz JM, Lombardo C, Micheli A, Capocaccia R: Comparative cancer survival information in Europe. Eur J Cancer 2009, 45:901–908. 28. Mueller RP, Soffietti R, Abacioglu MU, Villa S, Fauchon F, Baumert BG, Fariselli L, Tzuk-Shina T, Collette L, Kocher M: Adjuvant Whole Brain Radiotherapy Versus Observation After Radiosurgical or Surgical Resection for 1–3 Cerebral Metastases: Results of the OERTC 22952–26001 Study [abstract]. J Clin Oncol 2009, 27(s15). 29. Tyldesley S, McGahan C: Utilisation of radiotherapy in rural and urban areas in British Columbia compared with evidence-based estimates of radiotherapy needs for patients with breast, prostate and lung cancer. Clin Oncol (R Coll Radiol) 2010, 22:526–532. 30. Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, Howell D, Konski A, Kachnic L, Lo S, Sahgal A, Silverman L, von Gunten C, Mendel E, Vassil A, Bruner DW, Hartsell W: Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline. Int J Radiat Oncol Biol Phys 2011, 79:965–976. 31. Wu JS, Wong R, Johnston M, Bezjak A, Whelan T: Meta-analysis of dose- fractionation radiotherapy trials for the palliation of painful bone metastases. Int J Radiat Oncol Biol Phys 2003, 55(3):594–605. 32. Chow E, Harris K, Fan G, Tsao M, Sze WM: Palliative radiotherapy trials for bone metastases: a systematic review. J Clin Oncol 2007, 25:1423–1436. 33. Hartsell WF, Konski AA, Lo SS, Hayman JA: Single fraction radiotherapy for bone metastases: clinically effective, time efficient, cost conscious and still underutilized in the United States? Clin Oncol (R Coll Radiol) 2009, 21(9):652–654. Submit your next manuscript to BioMed Central doi:10.1186/1748-717X-7-131 and take full advantage of: Cite this article as: Expósito et al.: Use of palliative radiotherapy in brain and bone metastases (VARA II study). Radiation Oncology 2012 7:131. • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

Radiation OncologySpringer Journals

Published: Aug 3, 2012

There are no references for this article.