An analysis of radiation therapy patterns among more than 12,000 Medicare patients treated for bone metastases found that 23.4% received extended-fraction radiation therapy, “wasting both health-care dollars and precious patient time,” according to the investigators.1 One-third of the treating physicians had an extended-fraction radiation rate or more than 30% during the study period 2016 to 2018, despite recommendations issued by the American Society for Radiation Oncology (ASTRO) in 2013 against the routine use of extended-fraction radiation for palliating bone metastases.
According to the ASTRO Choosing Wisely recommendations, “Strong consideration should be given to a single 8-Gy fraction for patients with a limited prognosis or with transportation difficulties.”2 Yet, the study found that only 9% of patients received single-fraction radiotherapy.
“That is low, and I would hope it would be higher,” said study coauthor Fumiko Chino, MD, of the Department of Radiation Oncology at Memorial Sloan Kettering Cancer Center (MSK), New York, in an interview with The ASCO Post. She noted that although the use of extended-fraction radiation for bone metastases is rare at MSK, as a practicing radiation oncologist who is active in social media and whose mother, sister, and brother are radiation oncologists, she was aware that radiation therapy practices vary, and “single-fraction radiation is still underutilized.” Therefore, she was not shocked by the finding but “saddened.”
Declining Use of Extended Fractions
The use of extended-fraction radiotherapy for bone metastases has declined, from a rate of 50% in 2006 to 2009, to 36% in 2012 to 2015, to 23.4% in the current study. “The Choosing Wisely campaign really did help,” Dr. Chino said. Studies showing that single-fraction radiation can be as effective as extended-fraction radiation have been published since the 1990s,3-6 but “it takes a while for high-quality evidence-based medicine to trickle down—sometimes even decades,” Dr. Chino said. “It is more commonly known now that 8 Gy × 1 is an acceptable treatment, and it might be ideal for someone who has transportation issues, is at the end of life, or has other concerns related to social situations.”
Concern about retreatment may deter some radiologists from using single-fraction radiation. The ASTRO recommendations note, “Studies suggest equivalent pain relief following 30 Gy in 10 fractions, 20 Gy in 5 fractions, or a single 8-Gy fraction.” But, the recommendations also point out, “A single treatment is more convenient but may be associated with a slightly higher rate of retreatment to the same site.”
Modern Cohort
Researchers analyzed data for 12,221 Medicare beneficiaries who underwent two-dimensional (2D) or three-dimensional (3D) radiation therapy bone metastases between 2016 and 2018. Dr. Chino noted that colleagues who had read the study “are very appreciative of the fact we were able to show a modern cohort. Utilization is changing in the modern era after the Choosing Wisely guidelines and certainly in the context of COVID-19.”
For the study, 11 to 20 fractions were considered extended-fraction radiotherapy, and a median of 15 fractions were received in this category (interquartile range = 13–15 fractions). Nonextended radiation was classified as 1 to 10 fractions, and a median of 8 fractions were received in this group (range = 5–10 fractions).
Primary cancer sites included the breast, lungs, and prostate. The median age of the patients was 75.6 years. “Reassuringly, patient age > 85 years was associated with use of ≤ 10 fractions, suggesting that physicians were appropriately considering remaining survival time in the treatment decision,” the researchers noted. They also reported, however, “it is concerning that one-sixth of patients who died within 6 months in our study received extended-fraction [radiotherapy].”
“For people who have a limited life span, we should be taking up less of it with treatment, if we can give them the same benefit with something shorter.”— Fumiko Chino, MD
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“For people who have a limited life span, we should be taking up less of it with treatment, if we can give them the same benefit with something shorter,” Dr. Chino commented.
Physician Practice Patterns
The patients in the study had been treated by a total of 1,432 physicians. For the 382 physicians who treated more than 10 attributed patients, the researchers calculated the percentage of patients receiving extended fractions. “Outlier physicians were defined as those whose extended-fraction radiotherapy rate was ≥ 30% on the basis of an expert consensus threshold established by the current study’s coauthors, who include radiation oncologists, policymakers, and health services researchers. This was derived from data indicating that approximately 34% of metastatic bone lesions may have complicating features, excluding them from randomized trials of 1- to 10-fraction regimens,” the researchers explained.
“There was a healthy debate about what we would consider to be a reasonable rate of extended fractionation, and 30% is a conservative metric, because there are certain unique patients who may require extended fractionation,” Dr. Chino stated. “There are limited reasons to use extended fraction,” she said, “but it should be less and less of our practice.”
“Of the 382 eligible physicians who treated at least 10 patients, 33.2% used extended-fraction radiotherapy more than the expert consensus threshold of 30%,” the researchers reported.
Influencing Factors
Physicians who graduated from medical school more than 30 years ago were more likely to use extended-fraction radiotherapy. The authors hypothesized that those physicians “may be less aware of the newer data (primarily emerging from 2000 onward) supporting 1- to 10-fraction radiotherapy as valid techniques. Campaigns such as Choosing Wisely may have particularly targeted and influenced physicians in training, who may then have entered practice during this study’s years.”
Physicians practicing in the South (vs the Northeast and Midwest) were more likely to use extended-fraction radiation. Among the top 10 outlier physicians, 6 practiced in Florida. Physicians who treated at least 20 patients over the course of the study were more likely to use extended-fraction radiotherapy.
Financial Considerations
“There are financial disincentives toward using shorter fractions, because with radiation as the current payment model stands, you get paid per treatment. So, when you reduce a patient from 15 treatments down to 5 treatments, or 15 down to 1, you may be literally taking money out of your own pocket,” Dr. Chino said. “I don’t think physicians are necessarily greedy,” she stressed. However, financial considerations, along with unease about using fewer fractions and feedback from partners concerned about safety, “come together maybe to disincentivize people from adopting a single-fraction rate.”
“The recently announced radiation oncology–specific alternative payment model may avoid the pitfalls of the current fee-for-service system that does not reliably incentivize delivery of the most cost-effective treatment,” the researchers noted. “Unfortunately,” Dr. Chino said, “that model was delayed and faces additional delays because of the COVID-19 pandemic.”
Under the bundled payment model proposed by the federal Office of Management and Budget “for uncomplicated bone metastases, which is the focus of our study, you would get one payment,” Dr. Chino explained. “You could treat patients in 20 fractions or could treat them in a single fraction, but you would get paid the same. It would potentially incentivize people to pick the best treatment for each patient. If you really thought they would benefit from 20-fraction treatment, you would give them 20 fractions. But if a single fraction would be as effective, then you are going to get paid the same regardless.”
Transportation Issues
“[The study findings] serve as an impetus for both clinical practice and policy changes,” the authors noted. “Unnecessary protracted radiotherapy causes financial toxicity and prolonged time spent in treatment and in travel, resulting in decrements in quality of life.” They also pointed out that the ASTRO Choosing Wisely guidelines “specifically recommended strong consideration of single-fraction radiotherapy for patients with a limited prognosis, for whom durable local control may not be required, and for those with transportation difficulties.”
Travel to and from multiple treatments can be time-consuming and arduous, not only for patients, but for caregivers who serve as drivers and aides for patients who have trouble getting in and out of a car or public transportation. “In terms of financial toxicity, the additional burden of travel is enormous,” Dr. Chino said. She is the senior author of another study—accepted as a poster presentation at the ASCO20 Virtual Scientific Program—that concluded: “Patients may face significant nonmedical costs through parking fees, even at centers that reflect the highest standard of care. There was high variability in costs, with the potential for patients to pay hundreds of dollars in parking in order to receive their care.”7
The COVID-19 pandemic has imposed limitations on travel and hospital visits and led to “compelling conversations on social media,” Dr. Chino said. “I am in a Facebook group where we have many discussions among radiation oncologists about best treatment practices. I have heard mentioned many times about how, specifically during the COVID-19 pandemic, you absolutely should choose the shortest regimen you think is going to be effective because it can be a life-or-death difference if you are bringing patients in for multiple treatments and potentially exposing them to risk every time they leave the house. That has been an ongoing discussion online and in the community about shortening treatment if it has been shown to be effective, even if that is not your normal practice,” Dr. Chino said.
Actionable Targets
“Our data highlight actionable targets for intervening in these apparent instances of high-cost, low-value health care,” the researchers wrote. “Studies have demonstrated that clinical pathways, together with online peer review, for off-pathway choices are effective in reducing the use of extended-fraction radiotherapy for bone metastases.”
“No physician likes to be forced into a clinical pathway,” Dr. Chino noted. “I think that’s true across the board, but pausing to consider the reasons for interventions can be useful. We have seen that before in, for example, inappropriate prescription of antibiotics or inappropriate imaging.”
“Online peer review can be particularly useful in the COVID-19 era, when we can no longer sit around a table together.”— Fumiko Chino, MD
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She continued: “Peer review that goes on in chart rounds, when each radiation plan is reviewed by a group of peers, is where some of the outliers could be identified. For example, at MSK, no one is really using extended fractionation. That would be a red flag if it came up at chart rounds. It would be highly unusual, and the person who was prescribing an extended-fractionation course would certainly be pressed to justify why it was necessary to use more than 10 fractions,” Dr Chino said.
Building online peer review can bring in radiation oncologists who don’t have a similar group of peers within their own institutions. “There are a number of different systems in place. For example, people can log in remotely and then share their screens so everything can have a centralized review,” Dr. Chino said. “Online peer review can be particularly useful in the COVID-19 era, when we can no longer sit around a table together.”
It is the responsibility of the radiation oncology community to identify and address outlier physician practice patterns, Dr. Chino said. “A rising tide lifts all boats, which is why we have to bind together as a community and say certain standards and practices should be normalized—and when someone falls outside of that, he or she should be kindly questioned. There should be a check.”
DISCLOSURE: Dr. Chino has received research support from Varian, Chanel Endowment for Survivorship Research, and the Radiation Oncology Institute.
REFERENCES
1. Gupta A, Wang P, Sedhom R, et al: Physician practice variability in the use of extended-fraction radiation therapy for bone metastases: Are we choosing wisely? JCO Oncol Pract. April 13, 2020 (early release online).
2. Choosing Wisely: ASTRO releases list of five radiation oncology treatments to question as part of national Choosing Wisely campaign. September 23, 2013. Available at https://www.choosingwisely.org/astro-releases-list-of-five-radiation-oncology-treatments-to-question-as-part-of-national-choosing-wisely-campaign. Accessed June 8, 2020.
3. Bone Pain Trial Working Party: 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: Randomised comparison with a multifraction schedule over 12 months of patient follow-up. Radiother Oncol 52:111-121, 1999.
4. Steenland E, Leer JW, van Houwelingen H, et al: The effect of a single fraction compared to multiple fractions on painful bone metastases: A global analysis of the Dutch Bone Metastasis Study. Radiother Oncol 52:101-109, 1999.
5. Hartsell WF, Scott CB, Bruner DW, et al: Randomized trial of short- vs long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst 97:798-804, 2005.
6. Kaasa S, Brenne E, Lund J-A, et al: Prospective randomised multicenter trial on single fraction radiotherapy (8 Gy x 1) versus multiple fractions (3 Gy x 10) in the treatment of painful bone metastases. Radiother Oncol 79:278-284, 2006.
7. Lee A, Shah K, Byun J, et al: Nickel and dimed: Parking fees at NCI-designated cancer centers. ASCO20 Virtual Scientific Program. Abstract 2029.
