Palliative radiation oncology programs: improving value through high-quality and cost-effective care

Introduction

An estimated 40% of all radiation treatments are delivered with non-curative intent, and there is strong evidence that this cohort of patients would benefit from the integration of palliative care. Results of several studies spurred the Annual Meeting of the American Society of Clinical Oncology (ASCO) 2016 guideline and the American Society for Radiation Oncology (ASTRO) Choosing Wisely campaign to recommend early integration of palliative care into routine oncologic care (1,2). While palliative radiation therapy (PRT) has been a hallmark of radiation therapy (RT) for decades, efforts to enhance and improve its applications have changed over the years ranging from efforts to reduce the number of fractions to the development of rapid access palliation programs to the full integration of palliative care providers within radiation oncology clinics (1,3-8). The goals of these measures have been to improve patient care and outcomes while minimizing the burden of care and costs.

The focus of this article is reviewing how palliative radiation oncology programs (PROPs) can aid not only in the integration of palliative care principles into PRT, but also in enhancing patient care. For the purpose of this article, we define a PROP as any program, process, or system that has been developed to address a perceived institutional need for improving palliative radiation treatments and which enhances some elements of radiation delivery and the efficacy of providing care. In the discussion that follows, we outline the purpose and potential of a PROP and the key factors that support our advocacy for its adoption.

Why PROP?

Based on the growing recognition of and need for integration of palliative care into oncology care, several radiation oncology departments across the country have implemented a PROP or palliative consult service (9,10).

In 2017, ASTRO surveyed its practicing members to understand how they view their skill set related to providing primary palliative care and support beyond the clinical delivery of PRT. Of the 649 responses received, 91% believed that palliative and supportive cancer care is an important competency for radiation oncologists; 79% had a palliative medicine service at their institution or within their group practice; and 21% participated in palliative medicine rounds (11).

In a 2019 survey of members of the Society of Palliative Radiation Oncology, the majority of respondents held that the development of a dedicated PROP was important to the field of radiation oncology, although very few had a PROP in their place of practice (12). Despite good intentions, the PROP approach and components thereof have remained undervalued, underappreciated, and, therefore, underutilized in the field.

PROPs are designed to utilize and integrate palliative care principles, methodologies, and techniques in the delivery of palliative radiation treatment. In this model, radiation oncologists with expertise and experience in these principles are able to relieve acute pain and manage physical symptoms, facilitate completion of RT by reducing discomfort during treatment and keeping the RT courses short and manageable, and provide guidance and support for patients and families throughout the treatment process.

Establishing a sustainable PROP

While there are numerous benefits of a PROP, evidence-based standards and guidelines for how to build a sustainable program do not exist. Over the years, variations on PROPs have been instituted within academic departments based on the perceived institutional need. These include programs that have focused on inpatient radiation oncology consults, outpatient same-day pathways, and/or integration of palliative care specialists into radiation oncology care (3).

Importantly, the structure of a PROP can be tailored to different settings—from community hospitals to academic medical centers and for both inpatient and outpatient practices. With this in mind, institutions can create a program that best suits their organization’s needs and still augments the care that can be provided to a patient with advanced cancer. This approach should be systematic and incorporate formal workflow protocols, standardized care pathways, and best practice guidelines. Programs that have found a solid footing over the years include those with department-wide support and an infrastructure encompassing:

• Defined roles for radiation oncologists who deliver curative treatment, those who focus on non-curative palliative treatment, and/or for other healthcare practitioners with the training to manage palliative issues;
• Collaboration among radiation oncologists, medical and surgical oncologists, and institution-based palliative care teams;
• Utilization of hypofractionated radiation regimens.

The value they deliver

“Value” in health care is often described by improvements in quality and reductions in cost. In radiation oncology, a model such as PROP offers integration of quality improvement and cost reduction. This aligns with the value equation: Value = Quality/Cost (13), in that many attributes of a PROP directly drive up quality and drive down costs. Given the current reimbursement model for radiation oncology services in the United States, some may view PROPs as a potential revenue loss due to the required infrastructure, hypofractionation focus, and dedicated provider time, but value comes through various avenues including improvements in care, increased referrals for palliative RT, and decreased hospital costs. In this way, it functions similarly to the business model that has been described and supported palliative care (14). Following are several features of PROPs that have the potential to advance value in oncologic care delivery.

Timely access to care

Many PROPs function in a manner that ensures patients wait no longer than 24 to 48 hours to see a radiation oncologist. This expedited access benefits patients as it facilitates shorter time to treatments and, therefore, more rapid palliation of symptoms (15).

Optimized experience of a metastatic cancer patient

Radiation oncologists with specific expertise and interest in palliative care are equipped to address physical and emotional issues and challenges most pertinent to patients requiring PRT. They have the training and time to engage in difficult conversations with patients and families about living with cancer and address patients’ values and priorities as they change over the trajectory of their illness. Having palliative care expertise also prepares radiation oncologists to share prognostic information with accuracy and honesty.

These specialized conversations require a learned set of communication skills emphasizing the same patient-centered, empathy-driven approaches for directing conversations about serious illness and the communication frameworks utilized by palliative medicine physicians (16). When executed skillfully, conversations about serious illness lead to improved treatment decision-making in the metastatic setting (17). In this way, patients and families feel heard and supported, and most importantly, they feel empowered to make choices that are best aligned with their own values and priorities. While all radiation oncologists are able to engage in these conversations with patients and families, we contend that a radiation oncologist with a dedicated palliative/metastatic focus is particularly well suited to carry them out.

Specifically, a radiation oncologist with a specialty focus on palliative care is able to:

• Cultivate the necessary communication skillset for palliative care, including assessing pain medicine needs, discussing health care proxy and advance directives, and convening family conferences;
• Devote the time to carry out these conversations with patients and families;
• Share the information with the patients’ primary teams to ensure all providers are in accord regarding treatment goal.

While having a radiation oncologist specifically dedicated to palliative care may be practical in large practices and within medical centers with major cancer programs, it is unlikely to be feasible in smaller practices or those in outlying communities. However, that doesn’t mean that PROP principles cannot be effectively implemented in smaller institutions or private practices.

In the 2017 ASTRO survey of its members, community physicians rated higher confidence in all domains of palliative and supportive care and had less access to palliative care teams within their hospital or group practice (69% vs. 92%) compared to their academic counterparts. The authors suggested that the greater confidence indicated on the part of community physicians may be attributed to their inclination to develop competencies in palliative and supportive care in order to offer these services to patients when there is limited access to palliative care teams (11).

For radiation oncologists planning to join smaller practices, we would propose that it would be important to pursue skill development in palliative and supportive care during their residency training in radiation oncology at academic medical centers, particularly, those with an active PROP, which can help them facilitate these skills. Clearly, efforts spent by radiation oncologists learning how to integrate palliative care principles into their practice benefit their patients and the systems where they work.

Improved guideline-concordant care

Professional guidelines recommending that patients with metastatic cancer should not undergo extended radiotherapy have been largely disregarded (18). Extended fractionation schemes are overused, particularly in the final 30 days of life when longer courses of RT do not correlate with extended survival. One study by Santos et al. reported guideline-nonconcordant radiotherapy as defined by greater than 10 fractions in over 20% of patients over 65 years old within 90 days of death (19). Additionally, single-fraction palliative RT, which has been shown in numerous randomized trials to be equally efficacious to multiple-fraction regimens for palliation of bone pain, has had slow adoption in the United States (20). Despite efforts between 2011 and 2014 by the ASTRO, the American Board of Internal Medicine (ABIM), and the National Quality Forum (NQF) focusing on increasing the use of shorter regimens, the rate of single fractions only increased from 6.5% to 8.1% (4). Similarly, data from the National Cancer Database (NCDB) between 2010 and 2015 showed a slight rise in the use of single-fraction treatment from 3% in 2010 to 7% by 2015, but still these accounted for <10% of palliative courses (5). Nationally during the coronavirus disease 2019 (COVID-19) pandemic, the single fraction rate bumped from 7.6% in 2019 to 10% in 2020 and dropped back to 8.8% in 2021, which was not significantly different than the extended fractionation (>10 fx) rate of 10.2%, 8.8% and 7.7% in 2019, 2020 and 2021, respectively (21).

PROPs have been shown to promote guideline-concordant care related to hypofractionated regimens. Through the implementation of PROPs, multiple groups have demonstrated improvement in the utilization of hypofractionated courses of RT leading to a reduction in hospitalization costs and limiting the burden placed on patients with the overutilization of RT at the end of life. This has been the focus of both ASTRO and the American Academy of Hospice and Palliative Medicine (AAHPM) Choosing Wisely campaigns.

When Skamene et al. assessed the impact of a dedicated palliative radiation oncology service on the frequency of single fraction RT and hypofractionated radiation (≤5 fractions) among patients with bone metastases at the Dana-Farber/Brigham and Women’s Cancer Center, they found an increase in the proportion of single fraction RT (SF-RT) from 6.4% to 22.3% following implementation of the new PROP and from 26% to 53.5% for hypo-RT for bone metastases (22).

Standardized assessments of palliative care needs

PROPs can also provide a framework for standardizing the assessment of cancer-related symptoms, pain, physical and psychosocial issues, and spiritual needs (23). This can include ensuring the use of validated tools for measuring and monitoring pain, managing opioids optimally according to guidelines, and tracking quality-of-life (6). Standardizing these assessments across the advanced cancer population can make the patient experience more comfortable, provide screening measures to prompt referral to other specialized services, and provide educational and research opportunities to further improve and enhance the process.

Multidisciplinary team management

A dedicated PROP readily improves collaboration and integration with interdisciplinary palliative care teams when managing advanced cancer patients. This has been demonstrated through the development of palliative interdisciplinary team meetings, outpatient interdisciplinary cancer pain clinics (24), and integrating other advanced patient care needs such as social work and occupational therapy (25). Considering prior survey data that medical oncologists may be skeptical of the radiation oncologist’s role as part of the end-of-life care team (26), dedicated PROPs allow the opportunity to improve this perception and encourage an integral role in the care team. Additionally, a collaborative multidisciplinary approach improves communication and streamlines patient care, which may have some time savings for managing providers.

Reduction of hospitalization costs

At the Mount Sinai Hospital, the implementation of a Palliative Radiation Oncology Consult Service resulted in a $25,000 decreased median hospitalization cost for each patient who was receiving palliative radiation during a hospitalization (9). This cost savings was achieved in part by earlier and more frequently obtained palliative care consultations and co-management with the PROP service, more frequent utilization of shorter PRT courses, and an 8.5-day reduction in hospital length of stay for patients receiving PRT. The Mount Sinai PROP was also heavily involved in goals of care conversations, which led to earlier discharges and hospice enrollments.

Similarly, a novel inpatient radiation oncology consult service model, which included experts in palliative radiation and ablative techniques, evaluated at Memorial Sloan Kettering Cancer Center, demonstrated several benefits. The new PROP increased the delivery of specialty care, facilitated rapid access to palliative treatments, and decreased hospital length of stay by a median of one day overall and 3.5 days for those with indications for RT (10).

Primary palliative care skills learning for residents

While ideally any radiation oncologist should be able to obtain some level of palliative care expertise, a formal mandate to guide the skills necessary to assess competency is lacking in the requirements of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Radiology (ABR) (27). A reflection of the inadequacy of palliative care training among radiation oncology residents is highlighted by a recent survey of trainees, which showed that 79% rated their training as “not/minimally/somewhat” adequate in palliative care domains, despite almost all believing that palliative care was an important competency and 81% desiring more education (28). To this end, those who develop these skills achieve it through their own initiative.

While means to correct these inadequacies are needed, in the interim, PROPs provide a valuable option that ensures patients receive the holistic, focused approach from physicians who can manage all aspects and domains of their care. Additionally, PROPs serve as a vehicle for teaching palliative skills to medical providers and support personnel through didactic sessions, multidisciplinary conferences, and hands-on experience. While this does require concerted effort and adequate time, much of the learning comes in the process of caring for patients which minimizes some of the anticipated effort.

Satisfaction of patients, referring providers, and radiation oncology colleagues

Having radiation oncologists with a dedicated focus on PRT allows for improved patient follow-up and increased satisfaction for patients and referring physicians. This, in turn, leads to higher numbers of patients returning for additional treatment (29) as well as an increased number of new referrals.

Internal provider satisfaction

A study assessing responses of 102 radiation oncology care providers of a Supportive and Palliative Radiation Oncology (SPRO) service at four Boston-area academic centers showed that a significant majority of physicians believed the service allowed them to provide a higher quality of cancer care than those in institutions that did not have a dedicated service. Respondents also indicated that the service improved several quality measures related to palliative cancer care, including overall quality, communication with patients and families, staff experience, and appropriateness of treatment recommendations (23).

Patient satisfaction

A Canadian study on patient satisfaction evaluated responses from patients who did and did not (n=14) receive palliative care from an advanced practice clinical specialist radiation therapist (CSRT). The 10-question survey included “I was told everything that I wanted to know about my condition” and “I felt that the problem that I came with was sorted out properly.” Patients who received care from the CSRT (n=19) scored significantly higher than those who did not (n=14). Specifically, 89% of participants noted their experience with the CSRT was excellent; 78% strongly agreed or agreed that having a CSRT on the care team was important; and 89% strongly agreed or agreed that a CSRT was important to patients’ understanding of treatment (30).

Referring physician satisfaction

In 1996, the Odette Cancer Centre in Toronto, Ontario, introduced a Rapid Response Radiotherapy Program (RRRR) as an outpatient PRT clinic. Patients are typically referred to the program by internal and external physicians, including other radiation oncologists, medical oncologists, and family physicians. Since its establishment, the program has undertaken three analyses to determine its progress in meeting patient needs. The latest review looked at 2,742 patients referred to the program between August 2008 and June 2012, with a focus on wait times from referral to consultation and from consultation to treatment, as well as volume growth. The median wait time from referral to consultation was 3 days. In the group of 1,890 patients who underwent PRT, 60% were treated on the day of their consultation and 33%, within one to 6 days.

The authors noted that not only has their RRRR continued to improve in the delivery of timely PRT to patients, it has also demonstrated ongoing growth in referrals and a number of patients served. This was primarily due to easily accessible appointments, shorter wait times, and improved communication between referring physicians and treating radiation oncologists. The program’s continued success has led to the establishment of similar PRT clinics at other cancer centers in Canada and overseas. The ongoing success of this program suggests an area for future investigation (31).

Conclusions

Respected authors have raised concerns that broadening the scope of practice in radiation oncology to include palliative management may lead to decreased professional and technical revenue and may not be economically viable. A PROP allows other radiation oncologists to focus solely on their specialty subsites and continue to generate higher margins. Furthermore, having a service focused on patients with metastatic disease stands to both increase referrals for PRT and increase opportunities for prompt and guideline-concordant treatment recommendations for specialized technologies such as stereotactic body radiation therapy (SBRT), which non-palliative service dedicated radiation oncologists may be less likely to recommend.

While some successful PROPs exist and the benefits for patients are well-known, the absence of widespread adoption of PROPs represents a missed opportunity to optimize care for patients with advanced cancer (12). In essence, every radiation oncology practice has the capability of incorporating fundamental tenets of a PROP. The palliative care function need not be managed by a radiation oncologist. This role can also be assigned to an advanced practice radiation therapist or nurse practitioner, who play an integral role in several PROP models (30,31). Or a formal relationship can be established with the PROP and an on-site palliative medicine department to facilitate prompt consultations and interventions as needed.

In summary, a dedicated PROP can provide a specially trained radiation oncologist or another designated provider within the radiation oncology department who can coordinate and streamline access to quality palliative care that supports the patient and their family and enhances palliative education for referring providers and trainees. We submit that the essential nature of such a service, with its goal to improve quality of life by alleviating physical symptoms and emotional stress, enhancing the patient and family experience, and reducing costs related to PRT, provides a compelling argument for implementing a PROP. Whether a PROP consists of a single or several dedicated radiation oncologists with additional palliative care expertise or collaboration with palliative care teams, the program provides the capability and flexibility of efficiently and rapidly meeting the unpredictable, potentially urgent needs of patients undergoing PRT that exceed symptom management.

Acknowledgments

The authors would like to acknowledge Deborah C. Marshall, MD, whose survey data led to the writing of this topic discussion, and Linda Errante for editorial assistance.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Candice Johnstone and Michael Shing Fung Lee) for the series “Palliative Radiotherapy Column”, published in Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-171/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-171/coif). The series “Palliative Radiotherapy Column” was commissioned by the editorial office without any funding sponsorship. K.D. serves as the unpaid editorial board member of Annals of Palliative Medicine from February 2024 to January 2026. J.R.R. reports honoraria from the Arizona Dental Association and Castle Bioscience unrelated to this submission. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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