Improving the Lives of Advanced Cancer Patients with a Dedicated Palliative Radiotherapy Team

Focusing on the patient experience led this ACCC 2018 Innovator Award recipient to create a new approach to caring for patients with advanced cancer receiving radiation therapy for symptom palliation. Learn about Mount Sinai Hospital’s Palliative Radiation Oncology Consult service in this guest blog post by Kavita Dharmarajan, MD, MSc, assistant professor of radiation oncology and palliative medicine at the Mount Sinai Hospital and Tisch Cancer Institute, in New York, NY.

Two opposing forces exist within the field of palliative radiation therapy. Despite its high efficacy, radiation treatment sometimes places an increased burden of care and responsibility on patients and their families, as it can involve lengthy daily treatments lasting two weeks or longer. This necessitates prolonged hospitalizations for patients who are unable to travel back and forth to the radiation facility every day. Moreover, the immediate radiation-related side effects can sometimes outweigh treatment benefits in patients with very short life expectancies.

Traditionally, radiation oncology programs have been disease-focused rather than person-focused, and thus have not put a high priority on creating systems of care around palliative radiation therapy for advanced cancer patients. The consequence of this has been that palliative radiation therapy has involved lengthier courses than necessary, posing challenges for advanced cancer patients in terms of financial costs, travel time, and temporary decline in quality of life. In our hospital, we found that advanced cancer patients coming for radiation treatment often spent two weeks or longer receiving radiation treatment, had high unattended symptom burden, and needed multidisciplinary symptom management. This state of affairs at our program was in line with national practices. In the Radiation Oncology Department at Mount Sinai Hospital, we saw an opportunity to meld radiation oncology within a multidisciplinary work flow that included palliative care providers and other supportive oncology services in order to improve upon national benchmarks. Thus, we created a specialized service model called the Palliative Radiation Oncology Consult (PROC) service.

PROC is a radiation oncology–based clinical service that works closely with the palliative medicine service within our hospital. Its core mission is to care for the whole person, not merely the metastatic lesion causing the pain that prompted the initial consultation. PROC performs its mission in three ways:

1. By employing the shortest evidence-based and guideline-directed radiation treatment courses for metastases without compromising efficacy;
2. By discussing individual cases in a tumor board forum attended by representatives from multiple disciplines with an emphasis on symptom management; and
3. By routinely participating in goals of care conversations held often with patients, family members, palliative medicine specialists, and the patient’s primary oncology providers.

Since PROC’s inception in 2014, we have seen a five-day reduction in average hospital length of stay for inpatients receiving radiation; a $20,000 cost-savings per hospitalized radiation patient; a four-fold decrease in unnecessarily lengthy radiation courses; a corresponding two-to-threefold increase in the use of shorter but equally efficacious radiation courses; and a 15% increase in patients who met with a palliative care provider within a month of completing their radiation, all without compromising pain improvement. In fact, the rate of pain improvement experience increased by 7%.

Our three main takeaways from this program are:

1. Patients with advanced cancer benefit from a system of care that is person-focused rather than disease-focused.
2. A dedicated palliative radiation oncology service model with a person-focused mission at its core can greatly improve quality of life for advanced cancer patients referred for palliative radiation therapy.
3. The PROC model of multidisciplinary shared decision-making highlights the fact that we cannot make complex management decisions about advanced cancer patients in a silo. The bits and pieces of information gathered by the patient, family, and members of the disciplines on the care team are all critical in real-time decision-making about palliative radiation treatment and beyond.

At the ACCC 35th National Oncology Conference in October, Dr. Dharmarajan will be providing a closer look at how the PROC model was developed and sharing lessons learned to date.