Implementing a clinical pathway to standardize care for cancer patients experiencing bone metastases may help change physician behavior and reduce the number of painful radiation therapies used in treatment, according to an abstract presented at the 57th Annual Meeting of the American Society for Radiation Oncology (ASTRO) in San Antonio, TX.
Bone metastasis occurs when cells from a primary tumor break off and enter the bloodstream or lymph vessels, eventually settling in bones. This can cause significant pain, debilitation, and the need for narcotic pain medications. To treat these symptoms, physicians often use radiation therapies, which have been proven to be effective at relieving pain associated with bone metastases. However, treatment schedules can range from 1 to more than 25 daily radiation treatments. Courses with higher numbers of radiation treatments are often more costly and lead to a greater number of adverse events.
In 2011, after numerous studies demonstrated that single-treatment radiation is as effective as longer courses of radiation for achieving pain relief for certain patients, a group of radiation oncology experts published guidelines advising the use of single treatment in the management of symptoms associated with bone metastases. Two years later, a list of five recommendations were released as part of the national Choosing Wisely campaign, including a recommendation to not “use extended fractionation schemes (>10) for palliation of bone metastases.”
Despite this recommendation, a recent study reported that the proportion of patients receiving a single-fraction regimen is less than 5%, and 30% of patients receive courses with more than 10 fractions of radiation therapy.
At the ASTRO meeting, Brian Joseph Gebhardt, MD, University of Pittsburgh Cancer Center Institute, PA, presented an abstract describing how implementing a clinical pathway for bone metastases can help to reduce rates of treatment course with more than 10 fractions. The pathway was first developed in 2003, but was later modified to adhere to the recommended guidelines and encourage courses with single radiation treatments. Courses with more than 10 treatments were considered off pathway and subject to automatic peer review.
During the 11-year study, which included 12,678 unique courses of radiation in 16 academic and community sites within the UPMC CancerCenter network, Gebhardt’s team found that the proportion of patients treated with a single fraction rose from 7.6% to 15.8%, and the proportion of patients given multiple fractions fell from 18.6% to 9.7%. By the last year of the study, more than 90% of treatment courses included fewer than 10 fractions.
Further, academic sites seemed to adhere more closely to industry guidelines than community settings. Patients at academic sites were twice as likely to be treated with a single fraction and received more than 10 fractions in only 7.6% of cases.
Dr. Gebhardt and his team concluded that implementing the clinical pathway changed physician behavior over time across a large geographic area and led to the use of shorter, more cost-effective treatments.
As a retrospective study, some data regarding age, performance status, expected survival, site of primary malignancy, and other factors that may have influenced treatment decisions were unavailable for analysis. Additionally, because researchers were unable to distinguish the treatment courses used for retreatment in patients whose symptoms had recurred, these patients could not be excluded from analysis.
Dwight E. Heron, M.D., FACRO, FACR (UPMC CancerCenter and University of Pittsburgh School of Medicine, PA), a contributor to the study and an Editorial Advisor to Journal of Clinical Pathways, said in a press release, “This study really shows how having a clinical pathway can have a transformative effect on care.”
