General practitioners and referral for palliative radiotherapy: A population-based survey

doi:10.1016/j.radonc.2009.01.009

Radiotherapy and Oncology

Volume 91, Issue 2, May 2009, Pages 267-270

https://doi.org/10.1016/j.radonc.2009.01.009 Get rights and content

Abstract

Background and purpose

The suspicion exists that the referral rate for palliative radiotherapy (RT) is too low. RT, especially in a short series, is an essential and established modality within palliative cancer care for localised symptoms.

Material and methods

Questionnaires to evaluate the knowledge of palliative RT were sent to the 1100 general practitioners (GP’s) in the area of the Comprehensive Cancer Centre South in the Netherlands, covering about 2.6 million inhabitants. Four hundred and ninety-eight questionnaires were evaluated.

Results

Forty-six percent of the respondents had cared for patients referred for palliative RT in the last two years. Knowledge about the effects of palliative RT on bone metastases and spinal cord compression was good but about other palliative indications it was moderate to poor. Determinants of the actual referral for palliative RT were mainly patient related. GPs considered their own knowledge to be poor with only 10% reporting previous RT education.

Conclusions

It is absolutely necessary to inform GPs about the possibility of short series of palliative irradiation in order to improve their information for symptomatic cancer patients about all possibilities for palliative treatment.

Section snippets

Materials and methods

We developed a questionnaire, based on the Canadian survey [5]. Because GPs are often the medical care-takers in the last three months of the life of cancer patients, we concentrated only on palliative RT given in this terminal phase. The questionnaire included the following sections: respondent characteristics, number of patients in the palliative-terminal phase and number of patients referred for palliative RT, factors influencing referral for palliative RT, perception of the effectiveness of

Results

The characteristics of the responding GPs are shown in Table 1. The office of 95% of all physicians was located less than one hour from an RT Department, 77% said their patients were treated in one of the two RT Departments in the region, 23% in RT Departments in adjacent regions (Rotterdam, Utrecht, Nijmegen, Heerlen-Maastricht). Almost all GPs who completed the survey (96%) considered themselves to be the most important care-giver of terminal patients who received palliation. Most physicians

Discussion

In the South of the Netherlands almost all of the responding general practitioners appeared to be actively involved in the care of cancer patients in the terminal phase of their disease.

The profile of the responding GPs was roughly comparable with the profile of all Dutch GPs, as registered by NIVEL (Netherlands Institute for health services research) [10] (Table 1), with some overrepresentation of older, male physicians working alone and underrepresentation of young physicians [11]. Some

Conclusion

Most of the respondents considered their own knowledge about (palliative) RT and potential side-effects as modest, which might have led to fewer referrals for palliative RT for cancer patients. Special education in palliative RT and (treatment of) side effects, desired by almost all responding GPs, might give them more insight into the possibilities of palliative RT for haematuria, haemoptysis, airway obstruction, brain metastases, painful local processes, bone metastases and spinal cord

Acknowledgements

We thank all general practitioners who completed the questionnaire.

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Using ePROMs for follow-up after palliative radiotherapy: An exploratory study with patients and health care providers
2022, Patient Education and Counseling
Patients treated with palliative radiotherapy may experience symptoms decreasing their quality of life. Electronic patient-reported outcome measures (ePROMs) could provide an opportunity to follow-up patients after treatment.
A mixed-method study was performed using self-constructed questionnaires, focus groups and interviews with patients and health care professionals (HCP). A qualitative approach was used to code the data.
Forty-two patients, 21 radiation-oncologists, 15 general practitioners (GPs) and 24 home-care nurses completed a questionnaire. Ten patients, 6 radiation-oncologists, 14 GPs and 5 nurses were interviewed or participated in a focus group. Although patients and HCP are satisfied with current care, they believe ePROMs could improve follow-up, communication, continuity of care and self-management of symptoms. An easy to use, versatile ePROM platform seems to be important for successful implementation. Self-care tips and contact information should be added to relevant ePROM-questions, on both physical and psychological symptoms.
Patients and HCP agree that ePROMs could improve systematical clinical follow-up after palliative radiotherapy, with self-management support being the primary objective of such a system. Practice implications ePROMs after palliative radiotherapy seem feasible, the exact patient population that could benefit the most will need to be explored further; as the palliative population is very diverse.
Palliative Care Physicians and Palliative Radiotherapy, Knowledge and Barriers for Referring: A Cross-sectional Study
2020, Journal of Pain and Symptom Management
Citation Excerpt :
The treatment schedule did not show influences on physicians' decisions to refer patients for PRT in the present study. Because available evidence suggests that physicians who are knowledgeable about indications for and expected outcomes of PRT are more likely to appropriately refer patients, educational initiatives focused on identified needs have strongly been recommended.12,14,31,35 Educational interventions in Hospice and Palliative Medicine Fellows, palliative care teams, and general practitioners have demonstrated that even brief interventions may significantly impact the objective knowledge of core concepts about radiotherapy and increase the number of patients referred as a consequence.31,33,35,36
Palliative radiotherapy is effective in the management of symptoms resulting from advanced cancer. However, it remains underutilized. In developed countries, many factors have been linked to this phenomenon but data in developing and low-income countries, particularly in Latin America, are lacking.
To conduct a cross-sectional survey to explore palliative care physicians' knowledge of palliative radiotherapy and to investigate possible factors that limit patient referral.
This is a cross-sectional survey. An online questionnaire was sent to palliative care physicians (n = 170) registered in the Chilean Medical Society of Palliative Care directory.
The overall response rate was 58.8%. Nearly all respondents (98%) considered radiotherapy to be a useful treatment. Less than half the respondents (43%) had good knowledge of palliative radiotherapy. Knowledge was correlated with self-reported knowledge (P = 0.015), discussing cases with radiation oncologist (P = 0.001), and having attended educational events on palliative radiotherapy (P = 0.001). Patient reluctance, poor performance status, and family reluctance were identified as major barriers to the use of palliative radiotherapy. Physicians from cities other than the capital were more likely to be concerned about barriers such as distance to radiotherapy facilities (P = 0.01), the duration of the referral process (P = 0.01), and the lack of a radiation oncologist available for discussing cases (P = 0.01).
Several barriers affect referral to palliative radiotherapy. Some barriers seem to be more significant for physicians practicing in cities far from cancer centers. Physicians' knowledge is less than optimal and has been identified as a barrier to referral. Educational interventions and broadening the availability of cancer treatment resources are needed to improve the referral process.
Barriers to Referral for Palliative Radiotherapy by Physicians: A Systematic Review
2019, Clinical Oncology
Citation Excerpt :
Characteristics of the included studies are summarised in Table 2. Eight studies reporting on seven cohorts targeted mainly family physicians [16–19,21,22,24,25]. All but one of these used a form of a questionnaire originally developed by Samant et al. [16].
Palliative radiotherapy (PRT) can relieve symptoms and improve quality of life, but remains underutilised, possibly due to lack of referrals. We conducted a systematic review to study barriers impeding referral for PRT.
We searched EMBASE and MEDLINE to identify published studies of physician barriers to PRT referral. Data were synthesised using the percentage of respondents to the surveys in these studies who identified a given factor as a significant barrier to PRT referral. Barriers were categorised using a conceptual framework for radiotherapy access described by Sundaresan et al. (Aust Health Rev 40 (1), 2016, 11–18.)
EMBASE and MEDLINE searches returned 364 distinct papers. Of these, 11 papers (reporting on 12 cohorts of survey respondents) met the study inclusion criteria. All used a cross-sectional survey design. Seven cohorts included mainly family physicians, one surveyed mostly radiation oncologists, one surveyed hospice professionals and one surveyed members of the American Society of Clinical Oncology, the American Society of Radiation Oncology and the American Academy of Hospice Palliative Medicine. Many factors were identified as strongly influencing referral decisions. Only two cohorts of respondents were asked whether patient wishes influence referrals, but most (78–82%) respondents in these cohorts agreed that it was an important influence. Other important barriers included functional status (five cohorts asked, cited as a strong influence by 53–78% of respondents), short life expectancy (three, 44–59%), treatment length (five, 51–58%), inconvenience (six, 24–65%), cancer type (three, 55–80%), uncertainty of benefits (seven, 18–54%) and toxicity concerns (11, 18–43%). Hospice professionals most frequently cited factors related to expense of treatment.
Published high-quality data on barriers to PRT referral are limited to survey studies. Barriers to PRT referral include referrers' unfamiliarity regarding risks and benefits, cumbersome referral processes and perceived inconvenience of treatment. Interventions to increase referrals should be tailored to different professional groups and may include increased expert participation in multidisciplinary palliative care, shortening treatment courses and in-person interprofessional education.
Feasibility of radiation therapy in patients 90 years of age and older: A French multicentre analysis
2014, European Journal of Cancer
There are only scarce data on the management of patients aged 90 years or older with cancer, and more particularly on the place of radiation therapy (RT). We report the first large study on patients (pts) aged 90 years or older receiving RT.
Records from RT departments from five institutions were reviewed to identify pts 90 years of age and older who underwent RT for various malignant tumours treated between 2003 and 2012. Tumours’ characteristics were examined, as well as treatment specificities and treatment intent.
308 pts receiving 318 RT courses were identified, mean age was 93.2 years (standard deviation 2.8). Treatment was given with curative and palliative intent in 44% and 56%, respectively. Factors associated with a curative treatment were performance status (PS), place of life, previous surgery and tumour stage. Median total prescribed dose was 36 Gy (4–76 Gy). Hypofractionation and split course were used in 88% and 7.3%, respectively. Most toxicities were mild to moderate. RT could not be completed in 23 pts (7.5%). No long-term toxicity was reported. Median overall survival was 22.9 months (95CI: 15.5–42.7 months). Cancer was the cause of death in 8.7% and 46% of pts treated with curative and palliative intent, respectively.
This study shows that RT is feasible for patients aged 90 years or more. PS, place of life and tumour stage were factors of the therapeutic decision. There is no reason to withdraw pts with good general health condition from potentially curative RT, provided that careful attention is paid to factors of toxicity and to geriatric vulnerabilities.
A phase I study of short-course accelerated whole brain radiation therapy for multiple brain metastases
2012, International Journal of Radiation Oncology Biology Physics
To define the maximum tolerated dose (MTD) of a SHort-course Accelerated whole brain RadiatiON therapy (SHARON) in the treatment of patients with multiple brain metastases.
A phase 1 trial in 4 dose-escalation steps was designed: 12 Gy (3 Gy per fraction), 14 Gy (3.5 Gy per fraction), 16 Gy (4 Gy per fraction), and 18 Gy (4.5 Gy per fraction). Eligibility criteria included patients with unfavorable recursive partitioning analysis (RPA) class > or =2 with at least 3 brain metastases or metastatic disease in more than 3 organ systems, and Eastern Cooperative Oncology Group (ECOG) performance status ≤3. Treatment was delivered in 2 days with twice-daily fractionation. Patients were treated in cohorts of 6-12 to define the MTD. The dose-limiting toxicity (DLT) was defined as any acute toxicity ≥grade 3, according to the Radiation Therapy Oncology Group scale. Information on the status of the main neurologic symptoms and quality of life were recorded.
Characteristics of the 49 enrolled patients were as follows: male/female, 30/19; median age, 66 years (range, 23-83 years). ECOG performance status was <3 in 46 patients (94%). Fourteen patients (29%) were considered to be in recursive partitioning analysis (RPA) class 3. Grade 1-2 acute neurologic (26.4%) and skin (18.3%) toxicities were recorded. Only 1 patient experienced DLT (neurologic grade 3 acute toxicity). With a median follow-up time of 5 months (range, 1-23 months), no late toxicities have been observed. Three weeks after treatment, 16 of 21 symptomatic patients showed an improvement or resolution of presenting symptoms (overall symptom response rate, 76.2%; confidence interval 0.95: 60.3-95.9%).
Short-course accelerated radiation therapy in twice-daily fractions for 2 consecutive days is tolerated up to a total dose of 18 Gy. A phase 2 study has been planned to evaluate the efficacy on overall survival, symptom control, and quality of life indices.
Referral patterns of patients for palliative radiation therapy in British Columbia: A comparison between rural and urban family physicians
2012, Journal of Medical Imaging and Radiation Sciences
Previous studies have shown that palliative radiation therapy (PRT) is often underused, especially in rural and remote settings despite evidence supporting its effectiveness in managing symptoms from advanced or metastatic cancer.
To identify factors which influence family physicians (FPs) in British Columbia (BC) to refer patients for PRT at the BC Cancer Agency (BCCA) and to compare referral patterns between FPs in rural and urban areas.
A total of 1,001 questionnaires were sent to all FPs practicing in rural areas and randomly to FPs in urban areas (351 and 650, respectively). Rural and urban areas were chosen based on our previous study of utilization rates of PRT in BC. The questionnaire was adapted from a previously validated survey, and was used to obtain information on referral practices of FPs in BC. FPs who did not practice family medicine or where 80% of their practice was spent with either obstetrical or pediatric patients were excluded.
The overall response rate was 33% (44% rural vs. 28% urban). Rural FPs were more involved in both palliative care and metastatic cancer management of their patients (88% vs. 74%; P = .01 and 58% vs. 39%; P = .01). No difference was observed in the FPs' awareness of the BCCA's Radiation Oncology Program. The most significant factors influencing an FP to refer a patient for PRT were: poor functional status, inconvenience to travel and life expectancy. A higher proportion of rural FPs had 10 years or less of experience in family practice than the urban FPs (P = .03). There was no significant difference in the formal training or additional training between the rural and urban FPs.
This study found that FPs practicing in rural areas were more involved in palliative management of their patients and participated more in the care of patients with advanced or metastatic cancer than those in urban areas. They also more commonly referred patients for palliative radiotherapy than their urban counterparts. The reported factors that influenced rural and urban FPs to refer were patients' functional status and life expectancy, combined with uncertain benefit and potential side effects of radiotherapy. More than twice as many FPs from rural compared to urban areas were influenced by perceived inconvenience to travel for palliative radiotherapy. After controlling for potential confounding factors, FP awareness of the radiotherapy program, high participation in advanced, metastatic, or palliative care of cancer patients, formal training in radiation oncology, and additional training in palliative care were all associated with an increased probability of ever referring for palliative radiotherapy.
Des études précédentes ont démontré que la thérapie de radiation palliative (TRP) est souvent sous-utilisée, particulièrement dans les régions rurales et éloignées, malgré les preuves de son efficacité pour la gestion des symptômes dans les cas de cancers avancés ou métastatiques.
Déterminer les facteurs qui portent les médecins de famille (MF) de la Colombie-Britannique (C.B.) à renvoyer leurs patients en TRP au BC Cancer Agency (BCCA) et comparer les modalités de renvois des MF ruraux et urbains.
1001 questionnaires ont été envoyés à tous les MF ruraux et au hasard à des MF urbains (351 et 650, respectivement). Les régions rurales et urbaines ont été choisies à partir de nos analyses précédentes des taux d'utilisation de la TRP en C.-B. La rédaction du questionnaire s'est inspirée d'une étude précédemment validée et le questionnaire a servi à recueillir des données sur les pratiques de renvoi des MF en C.-B. Les MF qui n'exerçaient pas la médecine familiale où dont 80 % de l'exercice portait sur l'obstétrique ou la pédiatrie ont été exclus.
Le taux de réponde globale s'est élevé à 33 % (44 % en milieu rural et 28 % en milieu urbain). Les MF ruraux étaient plus engagés en soins palliatifs et en gestion des cancers métastatiques (88 % c. 74 %; P = 0,01 et 58 % c. 39 %; P = 0,01). On n'a pas relevé de différence dans la sensibilisation des MF au programme d'onco-radiologie du BCCA. Les facteurs d'influence les plus importants pour les MF qui envoient un patient en TRP sont: un état fonctionnel pauvre, la difficulté de voyager et l'espérance de vie. Une plus grande proportion des MF ruraux comptaient 10 ans ou moins d'expérience en médecine familiale, par rapport aux MF urbains (P = 0,03). Nous n'avons pas relevé de différence importante de la formation de base ou avancée entre les MF ruraux et urbains.
L'étude démontre que les MF ruraux adoptent plus les soins palliatifs et participent plus aux soins de leurs patients qui ont des cancers avancés ou métastatiques que les MF urbains. Ils renvoient aussi plus fréquemment les patients en radiothérapie palliative que leurs homologues urbains. Les facteurs mentionnés quant à la décision des MF ruraux et urbains de renvoyer les patients sont l'état fonctionnel du patient et l'espérance de vie, de même que les avantages incertains et les effets secondaires possibles de la radiothérapie. Plus de deux fois plus de MF ruraux que de MF urbains sont influencés par les inconvénients perçus par les déplacements pour recevoir de la radiothérapie palliative. Après le contrôle des facteurs confusionnels possibles, on a associé tous les facteurs suivants à l'augmentation de la probabilité de renvoyer les patients en radiothérapie palliative: sensibilité du MF au programme de radiothérapie, forte présence de cancer avancé, métastatique ou de soins palliatifs des patients cancéreux, formation en oncoradiologie et formation d'appoint en soins palliatifs.

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Palliative radiotherapyGeneral practitioners and referral for palliative radiotherapy: A population-based survey

Abstract

Background and purpose

Material and methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Conclusion

Acknowledgements

Clin Oncol (R Coll Radiol)

Curr Probl Cancer

Radiother Oncol

Eur J Surg Oncol

Eur J Cancer

Radiother Oncol

Int J Radiat Oncol Biol Phys

Palliative radiotherapy
General practitioners and referral for palliative radiotherapy: A population-based survey