Contemporary practice patterns for palliative radiotherapy of bone metastases: Impact of a quality improvement project on extended fractionation

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Pract Radiat Oncol


PURPOSE/OBJECTIVES: Radiotherapy (RT) effectively palliates bone metastases, though variability exists in practice patterns. National recommendations advocate against using extended fractionation (EF) with courses greater than ten fractions. We previously reported EF utilization of 14.8%. We analyzed practice patterns within a statewide quality consortium to assess EF use in a larger patient population following implementation of a quality measure focused on reducing EF.

MATERIALS/METHODS: Patients treated for bone metastases within a statewide radiation oncology quality consortium were prospectively enrolled from March 2018 through October 2020. The EF quality metric was implemented March 1, 2018. Data on patient, physician and facility characteristics, fractionation schedules, and treatment planning and delivery techniques were collected. Multivariable binary logistic regression was used to assess EF.

RESULTS: 1,445 consecutive patients treated with 1,934 plans were enrolled by 28 facilities. The median number of treatment plans per facility was 52 (range, 7-307). 60 different fractionation schedules were utilized. EF was delivered in 3.4% of plans. Initially, EF use was lower than expected and remained low over time. Significant predictors for EF use included complicated metastasis (OR 2.04, 95% CI: 1.04-4.02, p=0.04), lack of associated CNS or visceral disease (OR 2.27, 95% CI: 1.2-4.2, p=0.01), non-teaching versus teaching facilities (OR 8.97, 95% CI: 2.1-38.5, p<0.01), and treating physicians with more years in practice (OR 12.82, 95% CI: 3.9-42.4, p<0.01).

CONCLUSIONS: Within a large, prospective population-based dataset, fractionation schedules for palliative RT of bone metastases remain highly variable. Resource-intensive treatments including EF persist, though EF use was low following implementation of a quality measure. Complicated metastases, lack of CNS or visceral disease, treatment at non-teaching facilities or by physicians with more years in practice significantly predict use of EF. These results support ongoing efforts to more clearly understand and address barriers to high value radiation approaches in the palliative setting.

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ePub ahead of print