Does Dissemination of Guidelines Alone Increase the Use of Palliative Single-Fraction Radiotherapy? Initial Report of a Longitudinal Change Management Campaign at a Provincial Cancer Program

Abstract

Background: Despite level 1 evidence demonstrating the equivalence of single-fraction radiotherapy (SFRT) and multiple-fraction radiotherapy (MFRT) for the palliation of painful bone metastases, SFRT remains underused. In 2015, to encourage the sustainable use of palliative radiation oncology resources, CancerCare Manitoba disseminated, to each radiation oncologist in Manitoba, guidelines from Choosing Wisely Canada (CWC) that recommend SFRT. We assessed whether dissemination of the guidelines influenced SFRT use in Manitoba in 2016, and we identified factors associated with MFRT. Methods: All patients treated with palliative radiotherapy for bone metastasis in Manitoba from 1 January 2016 to 31 December 2016 were identified from the provincial radiotherapy database. Patient, treatment, and disease characteristics were extracted from the electronic medical record and tabulated by fractionation schedule. Univariable and multivariable logistic regression analyses were performed to identify risk factors associated with MFRT. Results: In 2016, 807 patients (mean age: 70 years; range: 35–96 years) received palliative radiotherapy for bone metastasis, with 69% of the patients having uncomplicated bone metastasis. The most common primary malignancies were prostate (27.1%), lung (20.6%), and breast cancer (15.9%). In 62% of cases, MFRT was used—a proportion that was unchanged from 2015. On multivariable analysis, a gastrointestinal [odds ratio (OR): 5.3] or lung primary (OR: 3.3), complicated bone metastasis (OR: 4.3), and treatment at a subsidiary site (or: 4.4) increased the odds of MFRT use. Conclusions: Dissemination of cwc recommendations alone did not increase SFRT use by radiation oncologists in 2016. A more comprehensive knowledge translation effort is therefore warranted and is now underway to encourage increased uptake of SFRT in Manitoba.

Exploring the utilization of single fraction radiation therapy for bone metastases at a community cancer centre

“…Consistent with Canadian literature, our multivariate analysis demonstrated that patients with bony metastases from a prostate primary tumour [7,37] and those with increasing age [28,29,38] were positively correlated with higher SFRT use ( Table 2 ). Higher rates of SFRT when treating bony metastases in the ribs and extremities have also been noted in previous studies [7,31] . Metastatic disease in the spine was associated with lower SFRT rates, a rather universal finding in other studies [7,28,37,38] .…”

“…Our results show that mass emailing of ROs with the updated guidelines did not increase our centres' SFRT rate. Kim et al (2020) and Olson et al (2016) both brought forward more personalized techniques of information sharing. By initiating audits, grand round presentations and surveys, they found a substantial increase in SFRT rates [31,41] .…”

“…Despite the equivalence in level of palliation and numerous advantages, SFRT rates remain consistently underutilized, while also showing high inter-centre and inter-physician variability. Since two thirds of bony metastases are uncomplicated, studies have pointed to this as a landmark of where utilization should be [31] . In light of this, in 2015, the Choosing Wisely Canada (CWC) Campaign, a movement to identify low-value, unnecessary and/or harmful services and procedures, recommended that SFRT should be prescribed for symptomatic and uncomplicated bone metastases [32] .…”

Creation of clinical algorithms for decision-making in oncology: an example with dose prescription in radiation oncology

“…Furthermore, as there is level I evidence showing equivalency of SF and MF regarding pain relief, it is proposed to use 1 × 8 Gy for the treatment of most uncomplicated bone metastases [ 34 ]. Yet, the majority of radiation oncologists continue to prescribe MF schemes in situations that can be considered “uncomplicated” [ 35 ]. Multiple reasons such as reimbursement issues or lacking knowledge have been postulated for this discrepancy [ 36 , 37 ].…”

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

“…Unfortunately, the simple publication and dissemination of guidelines on this subject produced unsatisfactory results. In fact, studies on guidelines impact have shown the lack of increased SFRT prescription 14 or only minimal and temporary variations. 15 Therefore, there is a clear need for new strategies with the aim of achieving a significant improvement of SFRT rates in this setting.…”