Meagan Doyle

Physician Expectations of Treatment Outcomes for Patients With Brain Metastases Referred for Whole Brain Radiotherapy

PURPOSE Patients with advanced cancer are referred to our Rapid Response Radiotherapy Program for quick access to palliative radiotherapy. The primary objective of this prospective study was to determine the physician expectations of the treatment outcomes for patients with brain metastases referred for whole brain radiotherapy (WBRT). The secondary objectives were to determine the factors influencing the expectations and to examine the accuracy of the physician-estimated patient survival. METHODS AND MATERIALS Patients were identified during a 17-month period. The referring physicians were sent a survey by facsimile to be completed and returned before the patient consultation. Information was sought on the patients disease status, the physicians expectations of WBRT, the estimated patient survival and performance status, and physician demographic data. RESULTS A total of 137 surveys were sent out, and the overall response rate was 57.7%. The median patient age was 66 years (range, 35-87), 78.5% had multiple brain metastases, 42.3% had a controlled primary tumor, and 62.3% had extracranial disease. WBRT was thought to stabilize neurologic symptoms, improve quality of life, and allow for a Decadron (dexamethasone) taper by > or =94.9% of the referring physicians; 87.0% thought WBRT would improve performance status; 77.9% thought it would improve neurologic symptoms; and 40.8% thought it would improve survival. The referring physicians estimated patient survival as a median of 6.0 months; however, the actual survival was a median of 2.5 months, for a median individual difference of 1.9 months (p < .0001). CONCLUSION Physicians referring patients with brain metastases for consideration of WBRT are often overly optimistic when estimating the clinical benefit of the treatment and overestimate patient survival. These findings highlight the need for education and additional research in this field.

Reasons for Poor Accrual in Palliative Radiation Therapy Research Studies

BACKGROUND Patients with advanced-stage cancer commonly have multiple symptoms, poor performance status, and limited life expectancies. Despite the need for evidence-based practice and guidelines for palliative radiation therapy (RT), conducting clinical palliative research has proven to be a challenge in the past because of low accrual rates and high patient attrition. We explore the change in accrual rates, reasons for nonparticipation in palliative RT clinical research trials, and factors that contributed to the increase in accrual over a 3-year period. PATIENTS AND METHODS A record was kept for all patients seen at the Rapid Response Radiotherapy Program between 2002 and 2005, including information on patient demographics, disease characteristics, and whether patients were accrued into >/=1 palliative research study at the time of clinic visit. If a patient did not participate in a study, the reason for nonaccrual was recorded. RESULTS Despite previous difficulties, changes to the methods of conducting palliative research and study design have resulted in an increase in patient accrual, from 14% to an average of approximately 60%. The implementation of a full-time clinical research assistant and a simple study design with realistic eligibility criteria contributed to the increase in patient participation. CONCLUSION Difficulties in conducting palliative clinical research trials were improved through changes in study design and research administration. Future clinics should use a dedicated clinical research assistant responsible for patient recruitment and study management. Studies should be designed specifically for the patient population receiving palliative care and should involve clearly defined and realistic eligibility criteria and brief assessments.

Involvement of Family Physicians in the Care of Cancer Patients Seen in the Palliative Rapid Response Radiotherapy Program

PURPOSE It is important for cancer patients to maintain continuity of care with their family physician (FP) while being followed at the cancer center. The primary objective of this study was to determine the perception of patients seen in the palliative Rapid Response Radiotherapy Program (RRRP) on FP involvement in their cancer care. Secondary objectives were to identify factors predicting for perceived FP involvement in patient cancer care. PATIENTS AND METHODS Consecutive patients were approached for study enrollment at the time of RRRP visit and asked to complete a 15-item survey. RESULTS Three hundred sixty-five patients were accrued over 15 months. Ninety-eight percent had an FP, and 43% felt their FP was involved in their cancer care. Eighty percent of patients were satisfied with the overall medical care provided by their FP, and 71% had been with their FP for > or = 5 years. The most common reason patients gave for perceiving limited FP involvement was the medical oncologist looking after all of their cancer needs. Multivariate analysis found that satisfaction with overall medical care provided by the FP, shorter time since last FP visit, seeing the FP since cancer diagnosis, and FP providing on-call service for after-hour emergencies all significantly predicted for patients perceiving FP involvement in their cancer care. CONCLUSION Less than half of patients surveyed perceived their FP as involved in their cancer care. Encouraging continuity of care between patients and FPs may allow for easier transition of care back to the FP once palliative treatment at the cancer center has finished and help facilitate end-of-life planning.

Palliative treatment of multiple bone metastasis.

To the Editor: We read with interest the article on the relationship between morphine and radiotherapy for management of symptomatic bone metastases from lung cancer by Ishiyama et al. [1]. We would like to take this opportunity to share with the readers our thoughts. Patients with advanced cancer often present with multiple bone metastases. Unlike systemic radionuclides or halfbody irradiation, external beam local radiotherapy often does not encompass all bony metastases. We therefore do not aim to substantially reduce patients’ analgesic consumption following external beam local radiotherapy. In fact, we do not usually have a tapering analgesic schedule for patients to follow. Ideally, these patients should be seen in regular follow-up by a palliative care physician to monitor their pain and analgesic use. In patients with multiple bone metastases, local radiotherapy to the most painful site (index site) can provide pain relief and unmask other painful areas, explaining why patients still require analgesics. In addition, new painful areas secondary to bone or visceral metastases may arise as a result of disease progression. Patients will require analgesics, but this does not necessarily mean the external beam local radiation has been ineffective. The two meta-analyses by Wu et al. [2] and Sze et al. [3] confirm the effectiveness of external beam local radiotherapy. The International consensus on endpoint measurements for future clinical trials on external beam radiotherapy [4] does not require that analgesic consumption be reduced in defining complete and partial responses. We encourage investigators to employ the consensus endpoints in reporting their results.