Are radiation oncologists following guidelines? An audit of practice in patients with uncomplicated bone metastases

Abstract

Background: Best-practice guidelines recommend single-fraction (SFRT) instead of multi-fraction radiation therapy (MFRT) for uncomplicated symptomatic bone metastases. SFRT is comparable to MFRT in relieving pain, convenient for patients, and cost-effective. Patterns of practice in Canada reveal that SFRT is underused, with significant variability across the country. We audited SFRT use and studied factors that may influence treatment decisions at a large academic tertiary care center in Quebec, Canada. Methods: Patients who received radiotherapy for uncomplicated bone metastases between February 2014 and March 2015 were reviewed. Age, gender, primary histology, site of metastases and performance status were identified as potential factors affecting fractionation. These were explored by Fisher's test on univariate analysis and logistic regression for multivariate analysis. Retreatment rates were analyzed with cumulative incidence and compared with Gray's test. Results: 254 radiotherapy courses were administered to 165 patients, 85.4% of which were delivered using a single fraction of 8 Gy. Patients age less than 70 years and those with breast histology were more likely to receive MFRT (p = 0.04; p = 0.0046). Performance status (ECOG) was a significant predictor of fractionation because of high correlations between young age, breast histology, and ECOG status (p = 0.03). Follow-up was too short in 40% of patients to derive definitive conclusions on retreatment. Conclusions: In accordance with current guidelines, our audit confirms that use of SFRT in patients with uncomplicated bone metastases at our center is high. We identified that patient age, primary histology, and performance status influenced fractionation. Incorporation of this quality indicator into our performance dashboard will allow assessment of retreatment differences and other criteria that may also influence treatment choice.

An Intensive Educational Intervention Significantly Improves the Adoption of Single Fractionation Radiotherapy in Uncomplicated Bone Metastases

“…As previously mentioned, other studies have shown increased use of SFRT in patients with worse performance status. 24,25 Unfortunately we are unable to confirm these results due to lack of available data in our series. Finally, ROs dedicated to palliative RT prescribed SFRT significantly more frequently than their peers.…”

“…Similar primary tumor-related differences were observed in other studies. For example, even in the study by Di Lalla et al, 25 lower SFRT rates were recorded in breast cancer patients. As previously mentioned, other studies have shown increased use of SFRT in patients with worse performance status.…”

“…Furthermore, this data confirms analogous results observed in other studies. 10,24,25 Similarly, a greater reluctance to prescribe SFRT has been observed in patients with breast cancer compared to lung cancer. The better prognosis of patients with BMs from breast cancer compared to BMs from lung cancer may explain this finding.…”

“…Indeed, this study design limited the analysis of a larger number of parameters that could potentially impact on SFRT prescription. In particular, data on patients’ performance status, which in other analyzes were correlated with SFRT, 24,25 are missing in our database. Furthermore, detailed data on systemic therapies at the time of RT are largely missing.…”

“…It is possible that in centers with only academic or only non-academic staff, the results may be different. In particular, the audit by Di Lalla et al, 25 performed in an academic center, recorded 85.4% rate of SFRT in uncomplicated BMs. Other studies confirmed that the rate of SFRT in this setting is higher in academic centers compared to community treatment centers.…”