Advertisement

Palliative radiation therapy in the last 30 days of life: A systematic review

  • Author Footnotes
    1 Present Address: Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA.
    Kyung Ran Park
    Footnotes
    1 Present Address: Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA.
    Affiliations
    Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
    Search for articles by this author
  • Chang Geol Lee
    Affiliations
    Department of Radiation Oncology, Yonsei University College of Medicine, Yonsei Cancer Center, Seoul, Republic of Korea
    Search for articles by this author
  • Yolanda D. Tseng
    Affiliations
    Department of Radiation Oncology, University of Washington, Seattle, USA
    Search for articles by this author
  • Jay J. Liao
    Affiliations
    Department of Radiation Oncology, University of Washington, Seattle, USA
    Search for articles by this author
  • Suresh Reddy
    Affiliations
    Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
    Search for articles by this author
  • Eduardo Bruera
    Affiliations
    Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
    Search for articles by this author
  • Sriram Yennurajalingam
    Correspondence
    Corresponding author at: Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA.
    Affiliations
    Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
    Search for articles by this author
  • Author Footnotes
    1 Present Address: Department of Radiation Oncology, University of Washington, Seattle, WA 98195, USA.
Published:October 16, 2017DOI:https://doi.org/10.1016/j.radonc.2017.09.016

      Abstract

      Purpose

      To investigate the utilization of palliative radiation therapy (RT), predictors for the use of RT, and symptom palliation following RT during the last 30 days of life through systemic review of literature.

      Materials/methods

      A systematic search of available medical literature databases was performed on patients receiving palliative RT in the last 30 days of life. A total of 18 studies were evaluated.

      Results

      The overall palliative RT utilization rates during the last month of life were in the range of 5–10% among patients who died of cancer and 9–15.3% of patients who received palliative RT. The most commonly used regimen was 30 Gy in 10 fractions (36–90%). Single fraction RT utilization ranged from 0% to 59%. ECOG performance status 3–4 was significantly associated with patients receiving RT in the last 30 days of life and shorter survival. Twenty-six percent of patients who survived less than 1 month were reported to show symptom palliation following RT.

      Conclusion

      Palliative RT was performed in approximately 10% of patients who died of cancer near their end of life, with the most commonly used regimen of 30 Gy in 10 fractions. This study suggests that greater use of shorter or single fraction regimens may be beneficial, especially in patients with poor performance status.

      Keywords

      Radiation therapy (RT) is one of the pivotal treatment options in the palliative management of symptomatic disease from advanced cancer. While palliative RT undoubtedly benefits patients with cancer in various stages of the disease, its use during the last month of life has recently been questioned, both in terms of symptom improvement and survival [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Murphy J.D.
      • Nelson L.M.
      • Chang D.T.
      • Mell L.K.
      • Le Q.-T.
      Patterns of care in palliative radiotherapy: a population-based study.
      ,
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ]. When survival is short, palliative RT may have minimal clinical benefit for patients, delay referral to hospice, and impede optimal end-of-life (EOL) planning and care delivery [
      • Jones J.A.
      • Lutz S.T.
      • Chow E.
      • Johnstone P.A.
      Palliative radiotherapy at the end of life: a critical review.
      ]. It is well-recognized that even experienced oncologists tend to overestimate patient prognosis [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Chow E.
      • Davis L.
      • Panzarella T.
      • Hayter C.
      • Szumacher E.
      • Loblaw A.
      • et al.
      Accuracy of survival prediction by palliative radiation oncologists.
      ,
      • Glare P.
      • Virik K.
      • Jones M.
      • Hudson M.
      • Eychmuller S.
      • Simes J.
      • et al.
      A systematic review of physicians’ survival predictions in terminally ill cancer patients.
      ]. As radiation oncologists incorporate life expectancy estimates into treatment decision-making, including selection of dose-fractionation prescription [
      • Tseng Y.D.
      • Krishnan M.S.
      • Sullivan A.J.
      • Jones J.A.
      • Chow E.
      • Balboni T.A.
      How radiation oncologists evaluate and incorporate life expectancy estimates into the treatment of palliative cancer patients: a survey-based study.
      ], overestimation of life expectancy may contribute to inappropriate use of longer fractionation regimens. This subjects patients and caregivers to longer active treatment at the EOL [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ]. Little is known regarding the frequency of palliative RT use and patterns of palliative RT in the last 30 days of life, despite its frequent utilization.
      The primary aim of the present study was to investigate the utilization of palliative RT, fractionation schedules, predictors for, and efficacy of palliative RT during the last 30 days of life through a systematic review of published literature. Results from this study would help build guidelines for palliative RT in patients at their EOL.

      Methods

      Online literature search of PubMed, CINAHL, and the Cochrane Review databases was performed to identify all original articles from January 1960 to December 2016. The search terms queried were ‘palliative radiation’ or ‘palliative radiotherapy’ and ‘end-of-life’, ‘last 30 days’, ‘last 1 month’, ‘terminally ill’, and ‘hospice’. The reference sections of the selected papers were manually searched for relevant publications.
      For this systematic review, we included studies published in English and reporting (1) RT utilization in the last 30 days of life (death within 1 month of completing RT), (2) risk variables associated with receiving RT during the last 30 days of life, and/or (3) the efficacy of RT in the last 30 days of life. Editorials and commentaries were excluded. Articles were screened on the basis of title and abstract, and then selected through reading the complete articles by two authors (Fig. 1). Independent data extraction from articles was made by two authors using predefined data template.
      A comprehensive systematic review using the PISMA guideline was conducted. However, a formal meta-analysis was not feasible because of the heterogeneity of patient cohort in published studies and the lack of minimal standards in reporting results.

      Results

      A total of 20 publications met our inclusion criteria were evaluated, of which 9 studies were from single institutions [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Nieder C.
      • Tollaali T.
      • Dalhaug A.
      • Haukland E.
      • Aandahl G.
      • Pawinski A.
      • et al.
      Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.
      ,
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ,
      • Patel A.
      • Dunmore-Griffith J.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation therapy in the last month of life.
      ,
      • Panoff J.
      • Simoneaux R.V.
      • Shah N.
      • Scott M.
      • Buchsbaum J.C.
      • Johnstone P.A.S.
      • et al.
      Radiation therapy at end of life in children.
      ,
      • Toole M.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation oncology quality: aggressiveness of cancer care near the end of life.
      ] and 11 studies from population registries (Table 1) [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Murphy J.D.
      • Nelson L.M.
      • Chang D.T.
      • Mell L.K.
      • Le Q.-T.
      Patterns of care in palliative radiotherapy: a population-based study.
      ,
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Matter-walstra K.W.
      • Achermann R.
      • Rapold R.
      • Klingbiel D.
      • Bordoni A.
      • Dehler S.
      • et al.
      Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.
      ,
      • Huang J.
      • Wai E.S.
      • Lau F.
      • Blood P.A.
      Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
      ,
      • Kress M.-A.
      • Jensen R.E.
      • Tsai H.-T.
      • Lobo T.
      • Satinsky A.
      • Potosky A.L.
      Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.
      ,
      • Huo J.
      • Du X.L.
      • Lairson D.R.
      • Chan W.
      • Jiang J.
      • Buchholz T.A.
      • et al.
      Utilization of surgery, chemotherapy, radiation therapy, and hospice at the end of life for patients diagnosed with metastatic melanoma.
      ,
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ,
      • Meeuse J.J.
      • van der Linden Y.M.
      • van Tienhoven G.
      • Gans R.O.B.
      • Leer J.W.H.
      • Reyners A.K.L.
      • et al.
      Efficacy of radiotherapy for painful bone metastases during the last 12 weeks of life: Results from the Dutch Bone Metastasis Study.
      ]. The patient populations included in these studies varied significantly across different studies. Ten studies examined patients who died of cancer (Table 2) [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Nieder C.
      • Tollaali T.
      • Dalhaug A.
      • Haukland E.
      • Aandahl G.
      • Pawinski A.
      • et al.
      Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.
      ,
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Matter-walstra K.W.
      • Achermann R.
      • Rapold R.
      • Klingbiel D.
      • Bordoni A.
      • Dehler S.
      • et al.
      Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.
      ,
      • Huang J.
      • Wai E.S.
      • Lau F.
      • Blood P.A.
      Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
      ,
      • Kress M.-A.
      • Jensen R.E.
      • Tsai H.-T.
      • Lobo T.
      • Satinsky A.
      • Potosky A.L.
      Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.
      ,
      • Huo J.
      • Du X.L.
      • Lairson D.R.
      • Chan W.
      • Jiang J.
      • Buchholz T.A.
      • et al.
      Utilization of surgery, chemotherapy, radiation therapy, and hospice at the end of life for patients diagnosed with metastatic melanoma.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ], 6 studies presented the frequency of palliative RT among patients receiving specifically palliative RT [
      • Murphy J.D.
      • Nelson L.M.
      • Chang D.T.
      • Mell L.K.
      • Le Q.-T.
      Patterns of care in palliative radiotherapy: a population-based study.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ,
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ], and 2 studies evaluated for patients receiving any RT (Table 3) [
      • Patel A.
      • Dunmore-Griffith J.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation therapy in the last month of life.
      ,
      • Panoff J.
      • Simoneaux R.V.
      • Shah N.
      • Scott M.
      • Buchsbaum J.C.
      • Johnstone P.A.S.
      • et al.
      Radiation therapy at end of life in children.
      ]. Most single institution studies examined patients who received palliative RT or any RT and most population based studies evaluated patients who died from cancer.
      Table 1Publications on palliative radiation therapy in the last 30 days of life.
      Classification of articlesNo. of articlesCountryNo. of articles
      Single Institution Study9China1
      Germany1
      Norway3
      USA4
      Population Based Study11Dutch1
      Norway1
      Swiss1
      Canada3
      USA5
      Total20
      Table 2Receipt of radiation therapy in the last 7, 14 and 30 days of life among patients who died from cancer.
      Data source

      (Author, publication year) [Reference]
      Total no. of patients and study cohortPrimary cancer typeEOL periodNo. of patients
      Number of patients who received RT at the end of life, EOL: End of life, NSCLC: Non-small cell lung cancer.
      (%)
      Shanghai Cancer Center
      Single institution study.


      (Zhang, Zhe et al. 2016)
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      410 decedents with cancer

      between 2007 and 2013
      All30 days28 (6.8%)
      Nordland Hospital
      Single institution study.


      (Nieder, Carsten et al. 2014)
      • Nieder C.
      • Tollaali T.
      • Dalhaug A.
      • Haukland E.
      • Aandahl G.
      • Pawinski A.
      • et al.
      Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.
      266 decedents with NSCLC

      between 2006 and 2013
      NSCLC30 days65 (24.4%)
      The Norwegian Cause of Death Registry
      Population based study.


      (Anshushaug, Malin et al. 2015)
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      723 decedents with cancer

      in 2005 & 2009
      All30 days

      14 days
      61 (8%)

      29 (4%)
      Alberta Cancer Registry
      Population based study.


      (Grendarova, Petra et al. 2015)
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      9863 decedents with cancer

      etween 2003 and 2010
      All30 days

      14 days
      988 (10%)

      542 (4.6%)
      Cancer Registry of Four Swiss Cantons
      Population based study.


      (Matter-Walstra, Klazien W. et al. 2015)
      • Matter-walstra K.W.
      • Achermann R.
      • Rapold R.
      • Klingbiel D.
      • Bordoni A.
      • Dehler S.
      • et al.
      Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.
      2,086 decedents with cancer in hospitals

      between 2006 and 2008
      All30 days244 (11.7%)
      BC Cancer Registry
      Population based study.


      (Huang, Jin et al. 2014)
      • Huang J.
      • Wai E.S.
      • Lau F.
      • Blood P.A.
      Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
      12,300 decedents with cancer

      between 2010 and 2011
      All30 days

      14 days
      614 (5%)

      268 (2.2%)
      SEER Medicare Database
      Population based study.


      (Guadagnolo, B. Ashleigh et al. 2013)
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      202,299 decedents with cancer

      between 2000 and 2007
      Lung, Breast, Prostate, Colorectal, Pancreas30 days15,287 (7.6%)
      SEER Medicare Database
      Population based study.


      (Kress, Marie-Adele Sorel et al. 2015)
      • Kress M.-A.
      • Jensen R.E.
      • Tsai H.-T.
      • Lobo T.
      • Satinsky A.
      • Potosky A.L.
      Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.
      39,619 decedents with cancer

      between 2004 and 2011
      Breast, Prostate, Colorectal14 days5,723 (14%)
      8 NCCN Member Institutes
      Population based study.


      (Kapadia, Nirav S. et al. 2012)
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      1098 decedents with NSCLC

      between Jan. 2001 and March 2010
      NSCLC30 days

      14 days
      209 (19%)

      115 (10%)
      SEER Medicare Database
      Population based study.


      (Huo, Jinhai et al. 2015)
      • Huo J.
      • Du X.L.
      • Lairson D.R.
      • Chan W.
      • Jiang J.
      • Buchholz T.A.
      • et al.
      Utilization of surgery, chemotherapy, radiation therapy, and hospice at the end of life for patients diagnosed with metastatic melanoma.
      816 decedents with metastatic melanoma

      between 2000 and 2007
      Melanoma30 days

      7 days
      88 (10.8%)

      11 (1.4%)
      * Single institution study.
      ** Population based study.
      Number of patients who received RT at the end of life, EOL: End of life, NSCLC: Non-small cell lung cancer.
      Table 3Receipt of radiation therapy in the last 7, 14 and 30 days of life among patients receiving radiation therapy.
      Data source (Author, publication year) [Reference]Study cohortPrimary cancer typeEOL daysNo. of patients
      Number of patients who received RT at the end of life.
      (%)
      University Hospital Dusseldorf
      Single institution study.


      (Gripp, Stephan et al. 2010)
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      216 patients receiving palliative RT

      between Dec 2003 and July 2004
      All30 days30 (13.9%)
      Nordland Hospital, Norway
      Single institution study.


      (Angelo, Kent et al. 2014)
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      579 patients receiving palliative RT

      during 2010 and 2011
      All30 days53 (9%)
      Johns Hopkins University School of Medicine
      Single institution study.


      (Ellsworth, Susannah et al. 2014)
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      339 patients receiving RT for bone

      metastases between 2007 and 2012
      All30 days89 (26%)
      Indiana University and Howard University
      Single institution study.


      (Patel, Anand et al. 2014)
      • Patel A.
      • Dunmore-Griffith J.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation therapy in the last month of life.
      852 (713
      Indiana University Hospital.
      , 139
      Howard University Hospital.
      ) patients receiving RT in 2010

      179 patients died in 2012
      All30 days

      7 days
      44(6.2%)
      Indiana University Hospital.
      , 10 (7.2%)
      Howard University Hospital.


      16 (2.2%)
      Indiana University Hospital.
      , 4 (2.9%)
      Howard University Hospital.
      Nordland Hospital, Norway
      Single institution study.


      (Nieder, Carsten et al. 2015)
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      873 patients receiving palliative

      RT between 2007 and 2011
      All30 days105 (12%)
      University of Miami
      Single institution study.


      Indiana University Health Proton Therapy Center
      Single institution study.


      (Panoff, Joseph et al. 2015)
      • Panoff J.
      • Simoneaux R.V.
      • Shah N.
      • Scott M.
      • Buchsbaum J.C.
      • Johnstone P.A.S.
      • et al.
      Radiation therapy at end of life in children.
      464 patients receiving photon therapy at age ≤21 between June 2000 and June 2014

      272 patients receiving proton therapy at age ≤21 between June 2008 and June 2013
      All30 days7 (1.6%)

      2 (0.7%)
      BC Cancer Agency
      Population based study.


      (Tiwana, Manpreet S. et al. 2016)
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      8301 patients (16,898 courses) receiving RT for bone

      metastases between 2007 and 2011
      All30 days

      14 days
      2443 (14.5%)

      709 (4.2%)
      SEER Medicare Database
      Population based study.


      (Murphy, James D. et al. 2013)
      • Murphy J.D.
      • Nelson L.M.
      • Chang D.T.
      • Mell L.K.
      • Le Q.-T.
      Patterns of care in palliative radiotherapy: a population-based study.
      21,279 patients receiving palliative RT

      between 2000 and 2007
      Lung, Breast,

      Prostate, Colorectal
      30 days

      14 days
      7,022 (33%)

      4,043 (19%)
      EOL, End of life.
      * Single institution study.
      ** Population based study.
      Number of patients who received RT at the end of life.
      Indiana University Hospital.
      § Howard University Hospital.

      Utilization of RT during the last 30, 14, and 7 days of life

      The overall palliative RT utilization rate in the last 30 days of life widely varied from 0.7% to 33% depending on the study cohort, region (country), and cancer type. The frequency of palliative RT use in the last 30 and 14 days of life ranged between 5% and 10% (mean ± standard deviation [STDEV] = 7.5 ± 2.1), and between 2.2% and 4.6% (mean ± STDEV = 3.5 ± 1.1) among patients who died from cancer, respectively (Table 2) [
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Huang J.
      • Wai E.S.
      • Lau F.
      • Blood P.A.
      Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ]. The range of palliative RT use rates in the last 30 days of life was 9–15.3% (mean ± STDEV = 12.1 ± 3.2) among patients receiving palliative RT, and 6.2–7.2% among patients receiving any RT (Table 3) [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ,
      • Patel A.
      • Dunmore-Griffith J.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation therapy in the last month of life.
      ]. The frequency of RT use in the last 30 days for pediatric patients receiving any RT with protons and photons was 0.7% and 1.6%, respectively [
      • Panoff J.
      • Simoneaux R.V.
      • Shah N.
      • Scott M.
      • Buchsbaum J.C.
      • Johnstone P.A.S.
      • et al.
      Radiation therapy at end of life in children.
      ]. Palliative RT was most frequently utilized in patients with lung cancer (Table 2, Table 4) [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Nieder C.
      • Tollaali T.
      • Dalhaug A.
      • Haukland E.
      • Aandahl G.
      • Pawinski A.
      • et al.
      Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Patel A.
      • Dunmore-Griffith J.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation therapy in the last month of life.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Matter-walstra K.W.
      • Achermann R.
      • Rapold R.
      • Klingbiel D.
      • Bordoni A.
      • Dehler S.
      • et al.
      Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.
      ,
      • Huang J.
      • Wai E.S.
      • Lau F.
      • Blood P.A.
      Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
      ,
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ].
      Table 4Receipt of radiation therapy (%) in the last 7, 14 and 30 days of life according to cancer type.
      Data source (No. of patients) [Reference]SEER-Medicare
      Patients died from cancer.
      (39,619)
      • Kress M.-A.
      • Jensen R.E.
      • Tsai H.-T.
      • Lobo T.
      • Satinsky A.
      • Potosky A.L.
      Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.
      SEER-Medicare
      Patients died from cancer.
      (202,299)
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      BC Cancer Registry
      Patients died from cancer.
      (12,300)
      • Huang J.
      • Wai E.S.
      • Lau F.
      • Blood P.A.
      Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
      Alberta Cancer Registry
      Patients died from cancer.
      (9863)
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      Norwegian Cause of Death Registry
      Patients died from cancer.
      (723)
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      Swiss Cancer Registry
      Patients died from cancer.
      (2,086)
      • Matter-walstra K.W.
      • Achermann R.
      • Rapold R.
      • Klingbiel D.
      • Bordoni A.
      • Dehler S.
      • et al.
      Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.
      BC Cancer Registry
      Patients receiving palliative RT for bone metastasis.
      (16,898)
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      Nordland Hospital
      Patients receiving palliative RT.
      (579)
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      Indiana University
      Patients receiving any RT.
      (63)
      • Patel A.
      • Dunmore-Griffith J.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation therapy in the last month of life.
      EOL days143014301430143030143030
      Lung11.25.411.38.317.691616.87.9SCLC 16.1 NSCLC 17.138
      Breast155.81.53.53.910.2589.91.304.8
      Prostate155.41.43.04.510.33612.52.27.6
      Colorectal142.41.01.91.24.1379.36.98.1
      Non-colorectal GI1.64.11.93.9
      Pancreas2.33611.1
      Head & neck5.914.7
      Hematologic1.03.64.38.110.73.0Lymphoma 14.3 Myeloma 4.2Lymphoma 11
      CNS/Brain1.63.14.27.37
      GYN0.82.42.65.444
      Urinary1.75.53.47.236Bladder 12.5
      Melanoma4.96
      Sarcoma7.9
      Others1.94.17.314.41210.55.17.4
      Overall147.62.25.04.6104811.74.29
      Study cohort: EOL: End of life, SCLC: Small cell lung cancer, NSCLC: Non-small cell lung cancer, GI: gastrointestinal, GYN: Gynecology.
      * Patients died from cancer.
      Patients receiving palliative RT for bone metastasis.
      Patients receiving palliative RT.
      § Patients receiving any RT.
      Regarding the proportion of time spent on treatment relative to the remaining life span, 33 (52%) of 63 patients who received RT within 30 days of death died during their treatment course, and 43 patients (69%) had their last treatment within 10 days before their death in a single institution study [
      • Toole M.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation oncology quality: aggressiveness of cancer care near the end of life.
      ]. Half of the patients spent greater than 60% of their remaining life span on therapy in a population based study [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ]. Two single intuition studies reported that 6 (10%) of 63 patients who died within 30 days of receiving RT and 12 (4%) of 339 patients whose final RT course was for bone metastases had their final RT on the days of their deaths [
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ,
      • Toole M.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation oncology quality: aggressiveness of cancer care near the end of life.
      ].

      Radiation treatment

      All results associated with radiation treatment procedure are shown in Table 5. The most common indication for RT was metastatic disease, involving bone (33–54%), brain (11–42%), central airway (16%), or spine (11–14%) for all cancer type [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ].
      Table 5Summary of radiation treatment.
      Data source [Reference]

      (Primary cancer type)
      RT SiteRT Fractionation/Duration% of patients not completing RTCauses for not completing RTResponse of RT
      Nordland Hospital*
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.


      (All cancer type)
      N/AThe most common RT regimen: 10 fractions of 3 Gy (36%), Other common regimens: 8 Gy SFRT (bone metastases), two fractions of 8.5 Gy (lung cancer), five fractions of 4 Gy (various indications)N/AN/AN/A
      Johns Hopkins University*
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.


      (All cancer type)
      N/ASFRT: 8%, 2–5 fractions: 19%, 6–10 fractions: 56%, >10 fractions: 17%N/AN/AN/A
      Indiana University*
      • Toole M.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation oncology quality: aggressiveness of cancer care near the end of life.


      (All cancer type)
      N/ANA54%N/AN/A
      University Hospital Dusseldorf*
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.


      (All cancer type)
      Brain: 42%

      (most common site)
      The median duration of RT: 15 days, Regimens of at least 30 Gy with fractions of 2–3 Gy in 90% of RT, RT Duration; 0–7 days: 20%, 7–14 days: 23%, 14–21 days: 43%, >21 days: 13%, Dose/Fraction; 2 Gy: 13.3%, 2–3Gy: 80%, 3.1–4 Gy: 6.7%58.1%Early death or deteriorating health statusWorsened: 51.6%

      Improved or stable: 25.8%

      Died before assessed: 22.6%
      Nordland Hospital*
      • Nieder C.
      • Tollaali T.
      • Dalhaug A.
      • Haukland E.
      • Aandahl G.
      • Pawinski A.
      • et al.
      Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.


      (NSCLC)
      Chest: 54%, Brain: 25%

      Spine: 14%, Other: 7%
      NAN/AN/AN/A
      Nordland Hospital, Norway
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.


      (All cancer type)
      Bone: 54%, Brain: 15%, Chest resulting from lung cancer: 12%The most common fractionation regimen was 3 Gy x 10 (43%), followed by 5–7 fractions of 4 Gy (22%).N/AN/AN/A
      BC Cancer Agency**
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.


      (All cancer type)
      Bone% of SFRT; Survival <2 weeks: 64.2%, Survival 2–4 weeks: 54.5%, Survival >4 weeks: 47.9%N/AN/AN/A
      Alberta Cancer Registry**
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.


      (All cancer type)
      Bone (most common site) followed by lung/mediastinal and brainSFRT: 19%, 2–5 fractions (mostly 5): 42%, 6–10 fractions (mostly 10): 21% , >10 fractions: 12% Unclear: 6%66%N/AN/A
      The Norwegian Cause of Death Registry**
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.


      (All cancer type)
      Bone: 33%

      Central airways: 16%

      Spinal cord: 11%

      Brain: 11%
      1–2 fractions: 33%

      3–5 fractions: 31%

      6–10 fractions: 25%

      >10 fractions: 11%
      82%Death: 27%

      Poor performance status : 45%

      Perforation of esophagus: 9% Progressive disease: 9%

      Septicemia: 9%
      N/A
      SEER Medicare Database**
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.


      (Lung, Breast, Prostate, Colorectal, Pancereas)
      N/ASFRT: 9.4%

      >10 days of treatment: 17.8%

      >5 days of treatment: 53.7%
      N/AN/AN/A
      SEER Medicare Database**
      • Murphy J.D.
      • Nelson L.M.
      • Chang D.T.
      • Mell L.K.
      • Le Q.-T.
      Patterns of care in palliative radiotherapy: a population-based study.


      (Lung, Breast, Prostate, Colorectal)
      N/AThe median duration of palliative RT: 16 daysN/AN/AN/A
      8 NCCN Member Institutes**
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.


      (NSCLC)
      Brain: 28%, Chest: 27%

      Spine: 25%

      Bones other than spine: 13%, Other: 8%
      1–3 fractions: 19%, 5 fractions: 9%, 6–9 fractions: 24%, 10 fractions: 30%, 11–15 fractions: 15%, >15 fractions: 2%53%Patient died: 17%, Patient/family preference: 21%, Cancer progression: 11%, Comorbidity: 9%, Toxicity: 6%, Other: 17%N/A
      * Single institution study, ** Population based study.
      NSCLC, Non-small cell lung cancer; SFRT, Single fraction RT; N/A, Not applicable (not documented in study).
      Ten fractions of RT was most commonly used (30–90%) [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ]. Single fraction radiotherapy (SFRT) utilization ranged from 0% to 59% depending on the treatment center with reported rates of 8–9.4% in the US and 19–59% in Canada [
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ]. A study of a single institution in Germany showed that SFRT was never applied [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ]. The proportions of patients receiving >10 fractions were 17–17.8%, 12%, and 11% in studies from the US, Canada, and Norway, respectively [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ].
      For RT technique, single field (74%) or 3-dimensional treatment planning (17%) was used in a population based study [
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ]. A study using the NCCN database of NSCLC reported that RT techniques used included conventional 2-dimensional RT (33%), 3-dimensional conformal RT (42%), intensity modulated RT (5%), stereotactic radiosurgery (37%), while 17% of cases did not report the RT technique [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ].
      The percentage of patients who did not complete RT was 53–82% [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Toole M.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation oncology quality: aggressiveness of cancer care near the end of life.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ]. The causes for not completing RT were poor performance status (47%), patient’s death (17–27%), cancer progression, comorbidity, and patient/family preference [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ].

      Efficacy of palliative RT in the last month of life

      Only 2 studies reported the efficacy of RT during the last month of life. Of 31 patients who died within 30 days after referral for palliative RT, despite palliative RT, condition worsened in 16 (51.6%) patients, and improved or remained stable in 8 (26%) patients. The remaining patients died before they could be assessed [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ]. The Dutch Bone Metastasis Study observed that the efficacy of RT for painful bone metastases during the last 12 weeks of life varied by time from death; 25%, 52%, 65%, and 81% for 1–4, 5–8, 9–12, and >12 weeks from death, respectively. Longer survival was associated with higher response rate, while 26% of patients that survived less than 1 month showed symptom response [
      • Meeuse J.J.
      • van der Linden Y.M.
      • van Tienhoven G.
      • Gans R.O.B.
      • Leer J.W.H.
      • Reyners A.K.L.
      • et al.
      Efficacy of radiotherapy for painful bone metastases during the last 12 weeks of life: Results from the Dutch Bone Metastasis Study.
      ].

      Predictors for RT and prognostic variables

      Table 6 demonstrates the predictors for the use of RT in the last month of life and prognostic variables. Among single institution studies, the patients who had Eastern Cooperative Oncology Group (ECOG) performance status (PS) 3–4, primary lung or bladder cancer, multiple metastases, and evidence of progressive disease were more likely to receive RT in the last month of life [
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ]. In population based studies, significant predictors for the use of RT in the last month of life included ECOG PS 3–4, earlier year of death, lung cancer cause of death, younger age, male sex, lower comorbidity score, shorter time from diagnosis to death, multiorgan involvement at diagnosis, urban residence (vs. rural), hospital type (highest in university hospitals), acute care admission, and higher income [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Murphy J.D.
      • Nelson L.M.
      • Chang D.T.
      • Mell L.K.
      • Le Q.-T.
      Patterns of care in palliative radiotherapy: a population-based study.
      ,
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Matter-walstra K.W.
      • Achermann R.
      • Rapold R.
      • Klingbiel D.
      • Bordoni A.
      • Dehler S.
      • et al.
      Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.
      ,
      • Kress M.-A.
      • Jensen R.E.
      • Tsai H.-T.
      • Lobo T.
      • Satinsky A.
      • Potosky A.L.
      Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.
      ,
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ].
      Table 6Predictors for receipt of radiation therapy in the last 14 and 30 days of life and prognostic variables.
      Data source [Reference]

      (Primary cancer type)
      EOL DaysSignificant co-variates for receiving RT
      Shanghai Cancer Center*
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.


      (All cancer type)
      30ECOG PS <3 and cardiopulmonary resuscitation were associated with the decision to administer RT.
      Nordland Hospital, Norway*
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.


      (All cancer type)
      30Lung or bladder cancer, Eastern Cooperative Oncology Group performance status of 3–4, low hemoglobin, opioid analgesic use, steroid use, and known progressive disease outside RT volume were significant predictors of receiving RT.
      Johns Hopkins University*
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.


      (All cancer type)
      30Lower mean Karnofsky performance status and inpatients at the time of initial radiation oncology evaluation were more likely to live ≤30 days of completing RT.
      Nordland Hospital, Norway*
      • Nieder C.
      • Tollaali T.
      • Dalhaug A.
      • Haukland E.
      • Aandahl G.
      • Pawinski A.
      • et al.
      Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.


      (NSCLC)
      30Lack of documented resuscitation preference and the presence of superior vena cava compression were more likely to receive RT.
      The Norwegian Cause of Death Registry**
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.


      (All cancer type)
      30ECOG PS 3–4, GPS 2, and synchronous metastases were more likely associated with receiving RT.
      Alberta Cancer Registry**
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.


      (All cancer type)
      30Higher comorbidity scores and the second half of study period (2007–2010) were associated with less end-of-life RT.
      Cancer Registry of Four Swiss Cantons**
      • Matter-walstra K.W.
      • Achermann R.
      • Rapold R.
      • Klingbiel D.
      • Bordoni A.
      • Dehler S.
      • et al.
      Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.


      (All cancer type)
      30Younger age, patients living in Ticino canton, and patients treated in university hospitals were significantly associated with receiving RT.
      SEER Medicare Database**
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.


      (Lung, Breast, Prostate, Colorectal, Pancereas)
      30Earlier year of death, lung cancer, younger age, male sex, non-Hispanic white, Hispanic or other race (versus non-Hispanic black), married status, Charlson comorbidity index of 0, urban residence, higher income level, no receipt of hospice, and southern SEER region were significantly associated with receiving RT.
      British Columbia Cancer Agency**
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.


      (All cancer type)
      14Site of primary, site of metastases, and treatment center were associated with receiving RT. Lung cancer patients and those with spinal metastases were more likely to receive RT.
      SEER Medicare Database**
      • Kress M.-A.
      • Jensen R.E.
      • Tsai H.-T.
      • Lobo T.
      • Satinsky A.
      • Potosky A.L.
      Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.


      (Breast, Prostate, Colorectal)
      14All others versus non-Hispanic white, younger age, urban area, married status, receiving prior RT and chemotherapy, shorter time from diagnosis to death, and stage IV were significantly associated with receiving RT.
      SEER Medicare Database**
      • Murphy J.D.
      • Nelson L.M.
      • Chang D.T.
      • Mell L.K.
      • Le Q.-T.
      Patterns of care in palliative radiotherapy: a population-based study.


      (Lung, Breast, Prostate, Colorectal)
      14Tumor site (lung cancer), increased age, increased comorbidity, and male sex were significant predictors of death within 2 weeks of receiving RT.
      8 NCCN Member Institutes**
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.


      (NSCLC)
      14Patients with stage IV disease or multiorgan involvement at diagnosis, and age <65 years at diagnosis were more likely to receive RT. There was significant interinstitutional variation in the EOL RT use.
      Prognostic variables
      Nordland Hospital, Norway*
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.


      (All cancer type)
      30ECOG PS 3–4, Brain metastases, Liver metastases, Bone metastases, Progressive disease, >1 diagnosis of cancer, Opioid analgesics, C-reactive protein >30 mg/l, Steroids, Leukocytosis, Pleural metastases and/or effusion were significant independent prognostic factors.
      University Hospital Dusseldorf*
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.


      (All cancer type)
      30Karnofsky performance status score <50%, dyspnea at rest, and brain metastases were independently associated with an unfavorable prognosis.
      * Single institution study, ** Population based study.
      EOL, End of life; NSCLC, Non-small cell lung cancer; ECOG PS, Eastern Cooperative Oncology Group Performance Status; GPS, Glasgow Prognostic Score.

      Palliative RT administration, and quality and cost of EOL care

      Receiving RT in the last 30 days of life was significantly associated with cardiopulmonary resuscitation [
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ], dying in hospital [
      • Nieder C.
      • Tollaali T.
      • Dalhaug A.
      • Haukland E.
      • Aandahl G.
      • Pawinski A.
      • et al.
      Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ], hospital admission [
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ], intensive care unit stay [
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ], and emergency department visits [
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Kress M.-A.
      • Jensen R.E.
      • Tsai H.-T.
      • Lobo T.
      • Satinsky A.
      • Potosky A.L.
      Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.
      ]. The cost of care was significantly higher for patients who underwent RT in the last 30 days of life compared to those who did not [
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ].

      Discussion

      The overall palliative RT utilization rates in the last 30 days of life were in the range of 5–10% among patients who died of cancer [
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Huang J.
      • Wai E.S.
      • Lau F.
      • Blood P.A.
      Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ], and 9–15.3% among patients receiving palliative RT [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ]. Most patients received 10 fractions of RT [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ], and SFRT use varied from 0 to 59% [
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ,
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ].
      Poor performance status was the most significant predictor for receiving RT in the last month of life [
      • Zhang Z.
      • Gu X.-L.
      • Chen M.-L.
      • Liu M.-H.
      • Zhao W.-W.
      • Cheng W.-W.
      Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
      ,
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ]. There was a high rate (53–82%) of incomplete treatment in this patient population with multifraction courses of RT mainly due to poor performance status, patient’s death, progressive disease, and comorbidity [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ]. Physicians consistently overestimate survival in patients with cancer at the EOL [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Chow E.
      • Davis L.
      • Panzarella T.
      • Hayter C.
      • Szumacher E.
      • Loblaw A.
      • et al.
      Accuracy of survival prediction by palliative radiation oncologists.
      ,
      • Glare P.
      • Virik K.
      • Jones M.
      • Hudson M.
      • Eychmuller S.
      • Simes J.
      • et al.
      A systematic review of physicians’ survival predictions in terminally ill cancer patients.
      ] and survival overestimates may have contributed to mismatched fractionation schedules and a high percentage of patients who have discontinued therapy [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ]. Two weeks of daily irradiation for patients with poor performance status at the EOL may place considerable burden for these patients and their families. SFRT is likely equally effective [
      • Lutz S.
      • Balboni T.
      • Jones J.
      • Lo S.
      • Petit J.
      • Rich S.E.
      • et al.
      Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline.
      ] and will reduce the burden and costs to patients with a short life expectancy. Forty percent of patients with painful bone metastases experienced pain reduction and better quality of life as early as 10 days after a single 8-Gy radiotherapy [
      • McDonald R.
      • Ding K.
      • Brundage M.
      • Meyer R.M.
      • Nabid A.
      • Chabot P.
      • et al.
      Effect of radiotherapy on painful bone metastases: a secondary analysis of the NCIC clinical trials group symptom control trial SC.23.
      ]. Thus, patients with poor performance status should receive SFRT whenever possible to minimize the time spent on treatment and enhance the quality of remaining life outside of the health care at the EOL.
      Practice patterns of palliative RT at the EOL widely varied across treatment centers, demographics, and geography. SFRT use is higher in Canada (19–59%) [
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ] than in the US (8–9.4%) [
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ]. The proportion of patients who spent >10 days receiving RT during the last 30 days of life was higher in the US (17–17.8%) [
      • Kapadia N.S.
      • Mamet R.
      • Zornosa C.
      • Niland J.C.
      • D’Amico T.A.
      • Hayman J.A.
      Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
      ,
      • Guadagnolo B.A.
      • Liao K.-P.
      • Elting L.
      • Giordano S.
      • Buchholz T.A.
      • Shih Y.-C.T.
      Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ] than in Canada and Norway (11–12%) [
      • Grendarova P.
      • Sinnarajah A.
      • Trotter T.
      • Card C.
      • Wu J.S.Y.
      Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
      ,
      • Anshushaug M.
      • Gynnild M.A.
      • Kaasa S.
      • Kvikstad A.
      • Grønberg B.H.
      Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
      ]. A study from BC Cancer Agency postulated that higher SFRT use in Canada may stem from the fact that 100% of RT is provided as a publicly-funded service in which RT prescription is not influenced by physician remuneration or patient’s ability to pay [
      • Tiwana M.S.
      • Barnes M.
      • Kiraly A.
      • Olson R.A.
      Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
      ]. Medical training, departmental policies, the potential higher rate of retreatment, and toxicity profile are concerns for not offering SFRT [
      • Crellin A.M.
      • Marks A.
      • Maher E.J.
      Why don’t British radiotherapists give single fractions of radiotherapy for bone metastases?.
      ,
      • Roos D.E.
      Continuing reluctance to use single fractions of radiotherapy for metastatic bone pain: an Australian and New Zealand practice survey and literature review.
      ]. Although likely multifactorial, the low frequency of SFRT use in the US is probably influenced by deeply rooted historical practice patterns favoring multi-fraction courses; additional contributing factors may include fraction-based reimbursement schemes in the US [
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ].
      The reason why a considerable number of patients at the EOL spent their remaining life span on RT and some patients had their final radiation treatment on the day of their death may be associated with survival overestimates [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Ellsworth S.G.
      • Alcorn S.R.
      • Hales R.K.
      • McNutt T.R.
      • DeWeese T.L.
      • Smith T.J.
      Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
      ,
      • Toole M.
      • Lutz S.
      • Johnstone P.A.S.
      Radiation oncology quality: aggressiveness of cancer care near the end of life.
      ]. Therefore, it is important to develop an objective survival prediction tool that allows life expectancy-adjusted therapeutic strategies at the EOL. Several objective tools have been developed to aid the clinician in formulating a prognosis of patients with poor survival, typically measured in days to weeks [
      • Simmons C.P.L.
      • McMillan D.C.
      • McWilliams K.
      • Sande T.A.
      • Fearon K.C.
      • Tuck S.
      • et al.
      Prognostic tools in patients with advanced cancer: a systematic review.
      ]. However, no simple prognostic model was capable of predicting mortality near EOL with high accuracy. Disease-specific models requiring larger databases may possess promising potential [
      • Angelo K.
      • Norum J.
      • Dalhaug A.
      • Pawinski A.
      • Aandahl G.
      • Haukland E.
      • et al.
      Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
      ,
      • Nieder C.
      • Angelo K.
      • Dalhaug A.
      • Pawinski A.
      • Haukland E.
      • Norum J.
      Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
      ]. The present study provides important stimuli for further research towards the development of decision-making tools that may reduce subjectivity in assessing the potential benefit of palliative RT for patients at the EOL.
      Despite the prescription of palliative RT during the last month of life, few studies have reported on the efficacy of RT in terms of symptom palliation or quality of life. Most patients with less than a 1 month life span may have been treated with little benefit [
      • Gripp S.
      • Mjartan S.
      • Boelke E.
      • Willers R.
      Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
      ,
      • Meeuse J.J.
      • van der Linden Y.M.
      • van Tienhoven G.
      • Gans R.O.B.
      • Leer J.W.H.
      • Reyners A.K.L.
      • et al.
      Efficacy of radiotherapy for painful bone metastases during the last 12 weeks of life: Results from the Dutch Bone Metastasis Study.
      ]. Therefore, future study is needed to investigate the benefit of RT at the EOL, as reported by patients.
      Careful consideration of the benefits of palliative RT in this patient population should be weighed and more research is needed to identify the patients who can benefit the most from palliative RT at the EOL. Lastly, further investigation is required to develop prognostic models that will improve the reliability of survival predictions, allowing more individualized life expectancy-adapted treatment planning.

      Conflict of interest

      None.

      References

        • Kapadia N.S.
        • Mamet R.
        • Zornosa C.
        • Niland J.C.
        • D’Amico T.A.
        • Hayman J.A.
        Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.
        Cancer. 2012; 118: 4339-4345https://doi.org/10.1002/cncr.27401
        • Murphy J.D.
        • Nelson L.M.
        • Chang D.T.
        • Mell L.K.
        • Le Q.-T.
        Patterns of care in palliative radiotherapy: a population-based study.
        J Oncol Pract. 2013; 9: e220-e227
        • Guadagnolo B.A.
        • Liao K.-P.
        • Elting L.
        • Giordano S.
        • Buchholz T.A.
        • Shih Y.-C.T.
        Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the united states.
        J Clin Oncol. 2013; 31: 80-87https://doi.org/10.1200/JCO.2012.45.0585
        • Gripp S.
        • Mjartan S.
        • Boelke E.
        • Willers R.
        Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: Reality or myth?.
        Cancer. 2010; 116: 3251-3256https://doi.org/10.1002/cncr.25112
        • Jones J.A.
        • Lutz S.T.
        • Chow E.
        • Johnstone P.A.
        Palliative radiotherapy at the end of life: a critical review.
        CA Cancer J Clin. 2014; 64: 295-310
        • Chow E.
        • Davis L.
        • Panzarella T.
        • Hayter C.
        • Szumacher E.
        • Loblaw A.
        • et al.
        Accuracy of survival prediction by palliative radiation oncologists.
        Int J Radiat Oncol Biol Phys. 2005; 61: 870-873https://doi.org/10.1016/j.ijrobp.2004.07.697
        • Glare P.
        • Virik K.
        • Jones M.
        • Hudson M.
        • Eychmuller S.
        • Simes J.
        • et al.
        A systematic review of physicians’ survival predictions in terminally ill cancer patients.
        BMJ. 2003; 327: 195-200
        • Tseng Y.D.
        • Krishnan M.S.
        • Sullivan A.J.
        • Jones J.A.
        • Chow E.
        • Balboni T.A.
        How radiation oncologists evaluate and incorporate life expectancy estimates into the treatment of palliative cancer patients: a survey-based study.
        Int J Radiat Oncol. 2013; 87: 471-478https://doi.org/10.1016/j.ijrobp.2013.06.2046
        • Nieder C.
        • Tollaali T.
        • Dalhaug A.
        • Haukland E.
        • Aandahl G.
        • Pawinski A.
        • et al.
        Active anticancer treatment during the final month of life in patients with non-small cell lung cancer.
        Anticancer Res. 2014; 34: 1015-1020
        • Zhang Z.
        • Gu X.-L.
        • Chen M.-L.
        • Liu M.-H.
        • Zhao W.-W.
        • Cheng W.-W.
        Use of palliative chemo- and radiotherapy at the end of life in patients with cancer: a retrospective cohort study.
        Am J Hosp Palliat Med. 2016; https://doi.org/10.1177/1049909116653733
        • Angelo K.
        • Norum J.
        • Dalhaug A.
        • Pawinski A.
        • Aandahl G.
        • Haukland E.
        • et al.
        Development and validation of a model predicting short survival (death within 30 days) after palliative radiotherapy.
        Anticancer Res. 2014; 34: 877-885
        • Nieder C.
        • Angelo K.
        • Dalhaug A.
        • Pawinski A.
        • Haukland E.
        • Norum J.
        Palliative radiotherapy during the last month of life: Predictability for referring physicians and radiation oncologists.
        Oncol Lett. 2015; 2015: 3043-3049https://doi.org/10.3892/ol.2015.3656
        • Ellsworth S.G.
        • Alcorn S.R.
        • Hales R.K.
        • McNutt T.R.
        • DeWeese T.L.
        • Smith T.J.
        Patterns of care among patients receiving radiation therapy for bone metastases at a large academic institution.
        Int J Radiat Oncol Biol Phys. 2014; 89: 1100-1105https://doi.org/10.1016/j.ijrobp.2014.04.028
        • Patel A.
        • Dunmore-Griffith J.
        • Lutz S.
        • Johnstone P.A.S.
        Radiation therapy in the last month of life.
        Rep Pract Oncol Radiother. 2014; 19: 191-194https://doi.org/10.1016/j.rpor.2013.09.010
        • Panoff J.
        • Simoneaux R.V.
        • Shah N.
        • Scott M.
        • Buchsbaum J.C.
        • Johnstone P.A.S.
        • et al.
        Radiation therapy at end of life in children.
        J Palliat Med. 2015; 18: 167-169https://doi.org/10.1089/jpm.2014.0219
        • Toole M.
        • Lutz S.
        • Johnstone P.A.S.
        Radiation oncology quality: aggressiveness of cancer care near the end of life.
        J Am Coll Radiol. 2012; 9: 199-202https://doi.org/10.1016/j.jacr.2011.11.006
        • Grendarova P.
        • Sinnarajah A.
        • Trotter T.
        • Card C.
        • Wu J.S.Y.
        Variations in intensity of end-of-life cancer therapy by cancer type at a Canadian tertiary cancer centre between 2003 and 2010.
        Support Care Cancer. 2015; 23: 3059-3067https://doi.org/10.1007/s00520-015-2676-y
        • Matter-walstra K.W.
        • Achermann R.
        • Rapold R.
        • Klingbiel D.
        • Bordoni A.
        • Dehler S.
        • et al.
        Cancer-related therapies at the end of life in hospitalized cancer patients from four swiss cantons: SAKK 89/09.
        Oncology. 2014; 88: 18-27https://doi.org/10.1159/000367629
        • Huang J.
        • Wai E.S.
        • Lau F.
        • Blood P.A.
        Palliative radiotherapy utilization for cancer patients at end of life in British Columbia: retrospective cohort study.
        BMC Palliat Care. 2014; 13: 49-58https://doi.org/10.1186/1472-684X-13-49
        • Kress M.-A.
        • Jensen R.E.
        • Tsai H.-T.
        • Lobo T.
        • Satinsky A.
        • Potosky A.L.
        Radiation therapy at the end of life: a population-based study examining palliative treatment intensity.
        Radiat Oncol. 2015; 10: 15-23https://doi.org/10.1186/s13014-014-0305-4
        • Huo J.
        • Du X.L.
        • Lairson D.R.
        • Chan W.
        • Jiang J.
        • Buchholz T.A.
        • et al.
        Utilization of surgery, chemotherapy, radiation therapy, and hospice at the end of life for patients diagnosed with metastatic melanoma.
        Am J Clin Oncol. 2015; 38: 235-241https://doi.org/10.1097/COC.0b013e31829378f9
        • Tiwana M.S.
        • Barnes M.
        • Kiraly A.
        • Olson R.A.
        Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
        BMC Palliat Care. 2016; 15https://doi.org/10.1186/s12904-015-0072-5
        • Anshushaug M.
        • Gynnild M.A.
        • Kaasa S.
        • Kvikstad A.
        • Grønberg B.H.
        Characterization of patients receiving palliative chemo- and radiotherapy during end of life at a regional cancer center in Norway.
        Acta Oncol. 2015; 54: 395-402https://doi.org/10.3109/0284186X.2014.948061
        • Meeuse J.J.
        • van der Linden Y.M.
        • van Tienhoven G.
        • Gans R.O.B.
        • Leer J.W.H.
        • Reyners A.K.L.
        • et al.
        Efficacy of radiotherapy for painful bone metastases during the last 12 weeks of life: Results from the Dutch Bone Metastasis Study.
        Cancer. 2010; : 2716-2725https://doi.org/10.1002/cncr.25062
        • Lutz S.
        • Balboni T.
        • Jones J.
        • Lo S.
        • Petit J.
        • Rich S.E.
        • et al.
        Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline.
        Pract Radiat Oncol. 2017; 7: 4-12https://doi.org/10.1016/j.prro.2016.08.001
        • McDonald R.
        • Ding K.
        • Brundage M.
        • Meyer R.M.
        • Nabid A.
        • Chabot P.
        • et al.
        Effect of radiotherapy on painful bone metastases: a secondary analysis of the NCIC clinical trials group symptom control trial SC.23.
        JAMA Oncol. 2017; 3: 953https://doi.org/10.1001/jamaoncol.2016.6770
        • Crellin A.M.
        • Marks A.
        • Maher E.J.
        Why don’t British radiotherapists give single fractions of radiotherapy for bone metastases?.
        Clin Oncol. 1989; 1: 63-66
        • Roos D.E.
        Continuing reluctance to use single fractions of radiotherapy for metastatic bone pain: an Australian and New Zealand practice survey and literature review.
        Radiother Oncol. 2000; 56: 315-322
        • Simmons C.P.L.
        • McMillan D.C.
        • McWilliams K.
        • Sande T.A.
        • Fearon K.C.
        • Tuck S.
        • et al.
        Prognostic tools in patients with advanced cancer: a systematic review.
        J Pain Symptom Manage. 2017; https://doi.org/10.1016/j.jpainsymman.2016.12.330