Palliative radiotherapy during the last month of life: Have COVID-19 recommendations led to reduced utilization?

Abstract

Background/Aim: The study aimed to evaluate practice changes in the time period of the early wave of the COVID-19 pandemic. Patients and Methods: This was a retrospective single institution study. We defined palliative radiotherapy (PRT) initiated before Saturday, March 14th as pre-COVID and PRT initiated later as during-COVID (through June 30th). Results: National COVID-19 recommendations led to a significant decrease in PRT with 10 or more fractions, while re-irradiation and radiotherapy during the final 30 days of life were equally common before and after these recommendations had been issued in March 2020. Conclusion: Rapid adoption of modified PRT regimens was feasible. However, the challenge of overtreatment in the final phase of the disease, due to inaccurate survival prediction, persisted.<p> <p>Palliative radiotherapy (PRT) is among the cornerstones of oncological approaches in patients with incurable cancer (1). In our institution, which has a dedicated PRT program that serves a small and scattered population of less than 200,000 inhabitants in rural North-Norway (large parts of Nordland County with a total of population of 243,000), overtreatment and 30-day mortality (30DM) has long been a topic of research (2-6). The first comprehensive analysis related to the time period 2007- 2009 (7). In 9% of patients, PRT was administered during the final 30 days of life. We were able to develop and validate a predictive model [presence of 6 parameters: lung or bladder cancer, Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 3-4, low serum hemoglobin, opioid analgesic use, steroid use, progressive disease outside the PRT volume], which correctly identified 75% of PRT courses administered during the final 30 days of life. Given that our further research focused on PRT and survival prediction, and that only three clinical oncologists assessed patients and prescribed PRT, we hypothesized that increased awareness and knowledge about factors predicting 30DM might have led to decreased 30DM in a later time period. Consequently, we evaluated our data obtained between 01.09.2013 and 31.08.2014 (8). We were disappointed to learn that even in our small facility, 30DM did not improve compared to the first study (17% in patients with metastatic cancer, 5% in those with non-metastatic cancer). In March 2020, the global COVID-19 pandemic also arrived in Norway. On March 10th, the Norwegian Institute of Public Health had registered 277 people with confirmed infection. Based on national recommendations distributed to all oncology departments, we encouraged the utilization of altered fractionation regimens with a focus on short overall treatment time, as well as a thorough assessment of the potential benefit of PRT, as also suggested by international groups (9, 10). The aim of the present analysis was to evaluate the impact of COVID-19-related changes, primarily regarding PRT during the final 30 days of life and secondarily regarding PRT with 10 or more fractions.<p> Patients and Methods<p> <p<We analyzed the treatment administered in the time period between 01.01.and 30.06.2020 and defined PRT initiated before Saturday, March 14th as pre-COVID and PRT initiated later as during-COVID. The analysis was performed on September 13th and survival data were available for all patients. The statistical evaluation employed the 2-tailed Fisher exact probability test (IBM SPSS v.25, significance was defined as p≤0.05 in two-sided tests).<p> Results<p> <p>Forty-seven patients were treated in the pre-COVID phase (0.9 started PRT each business day; 25 received PRT for bone metastases, 53%), including 5 re-irradiations (11%). The largest group consisted of patients with non-small cell lung cancer (n=15, 32%). Twenty-eight patients (60%) received 10 or more fractions. Only 3 patients (6%), all with metastatic cancer, were treated during the final 30 days of life.