title: Prevalence and Predictors of Inappropriate Delivery of Palliative Thoracic Radiotherapy for Metastatic Lung Cancer.
abstract: BACKGROUND
  High-level evidence has established well-recognized standard treatment regimens for patients undergoing palliative chest radiotherapy (RT) for stage IV non-small cell lung cancer (NSCLC), including treating with fewer than 15 fractions of RT, and not delivering concurrent chemoradiation (CRT) because of its increased toxicity and limited efficacy in the palliative setting.
  
  
  METHODS
  The study included patients in the National Cancer Database from 2004 to 2012 with stage IV lung cancer who received palliative chest radiation therapy. Logistic regression was performed to determine predictors of standard vs nonstandard regimens (>15 fractions or CRT). All statistical tests were two-sided.
  
  
  RESULTS
  There were 46 803 patients in the analysis and 49% received radiotherapy for longer than 15 fractions, and 28% received greater than 25 fractions. Approximately 19% received CRT. The strongest independent predictors of long-course RT were private insurance (odds ratio [OR] = 1.40 vs uninsured, 95% confidence interval [CI] = 1.28 to 1.53) and treatment in community cancer programs (OR = 1.49, 95% CI = 1.38 to 1.58) compared with academic research programs. The strongest factors that predicted for concurrent chemoradiotherapy were private insurance (OR = 1.38 95% CI = 1.23 to 1.54) compared with uninsured patients and treatment in community cancer programs (OR = 1.44, 95% CI = 1.33 to 1.56) compared with academic programs.
  
  
  CONCLUSIONS
  Approximately half of all patients with metastatic lung cancer received a higher number of radiation fractions than recommended. Patients with private insurance and treated in community cancer centers were more likely to receive longer courses of RT or CRT. This demonstrates that a substantial number of patients requiring palliative thoracic radiotherapy are overtreated and further work is necessary to ensure these patients are treated according to evidenced-based guidelines.
authors.affiliation: Department of Radiation Oncology, University of Illinois at Chicago, Chicago, IL (MK, RRW); Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL (MK, RM, RRW); Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (UM); Department of Radiation Oncology, Yale University, New Haven, CT (ZH); Department of Radiation Oncology, Rush University Medical Center, Chicago, IL (DJS). mkoshy@radonc.uchicago.edu.
authors.forename: Matthew
authors.initials: M
authors.lastname: Koshy
authors.affiliation: Department of Radiation Oncology, University of Illinois at Chicago, Chicago, IL (MK, RRW); Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL (MK, RM, RRW); Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (UM); Department of Radiation Oncology, Yale University, New Haven, CT (ZH); Department of Radiation Oncology, Rush University Medical Center, Chicago, IL (DJS).
authors.forename: Renuka
authors.initials: R
authors.lastname: Malik
authors.affiliation: Department of Radiation Oncology, University of Illinois at Chicago, Chicago, IL (MK, RRW); Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL (MK, RM, RRW); Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (UM); Department of Radiation Oncology, Yale University, New Haven, CT (ZH); Department of Radiation Oncology, Rush University Medical Center, Chicago, IL (DJS).
authors.forename: Usama
authors.initials: U
authors.lastname: Mahmood
authors.affiliation: Department of Radiation Oncology, University of Illinois at Chicago, Chicago, IL (MK, RRW); Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL (MK, RM, RRW); Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (UM); Department of Radiation Oncology, Yale University, New Haven, CT (ZH); Department of Radiation Oncology, Rush University Medical Center, Chicago, IL (DJS).
authors.forename: Zain
authors.initials: Z
authors.lastname: Husain
authors.affiliation: Department of Radiation Oncology, University of Illinois at Chicago, Chicago, IL (MK, RRW); Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL (MK, RM, RRW); Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (UM); Department of Radiation Oncology, Yale University, New Haven, CT (ZH); Department of Radiation Oncology, Rush University Medical Center, Chicago, IL (DJS).
authors.forename: Ralph R
authors.initials: RR
authors.lastname: Weichselbaum
authors.affiliation: Department of Radiation Oncology, University of Illinois at Chicago, Chicago, IL (MK, RRW); Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, IL (MK, RM, RRW); Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX (UM); Department of Radiation Oncology, Yale University, New Haven, CT (ZH); Department of Radiation Oncology, Rush University Medical Center, Chicago, IL (DJS).
authors.forename: David J
authors.initials: DJ
authors.lastname: Sher
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology* / Q000532:radiotherapy*; D059248:Chemoradiotherapy / Q000592:standards; D003153:Community Health Services; D016208:Databases, Factual; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D007348:Insurance, Health; D016015:Logistic Models; D008175:Lung Neoplasms / Q000473:pathology* / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010166:Palliative Care / Q000379:methods* / Q000592:standards*; D011237:Predictive Value of Tests; D015995:Prevalence; D017149:Private Sector; D014481:United States / Q000453:epidemiology