title: Utilization of palliative radiotherapy for bone metastases near end of life in a population-based cohort.
abstract: BACKGROUND
  Palliative radiotherapy (PRT) can significantly improve quality of life for patients dying of cancer with bone metastases. However, an aggressive cancer treatment near end of life is an indicator of poor-quality care. But the optimal rate of overall palliative RT use near the end of life is still unknown. We sought to determine the patterns of palliative radiation therapy (RT) utilization in patients with bone metastases towards their end of life in a population-based, publicly funded health care system.
  
  
  METHODS
  All consecutive patients with bone metastases treated with RT between 2007 and 2011 were identified in a provincial Canadian cancer registry database. Patients were categorized as receiving RT in the last 2 weeks, 2-4 weeks, or >4 weeks before their death. Associations between RT fractionation utilization by these categories, and patient and provider characteristics were assessed through logistic regression.
  
  
  RESULTS
  Of the 16,898 courses 1734 (10.3) and 709 (4.2%) were prescribed to patients in the last 2-4 weeks and <2 weeks of their life, respectively. Primary lung (8%) and gastrointestinal (6.9%) cancers received palliative RT more commonly in the last 2 weeks of life (OR 3.72 [2.86-4.84] & 3.33 [2.42-4.58] respectively, p <0.001). Among the 709 patients who received RT in the last 2 weeks of life, 350 (49), 167 (24), and 127 (18%) were for spine, pelvis, and extremity metastases, respectively. RT was prescribed most frequently to spine (5%) and extremity (4%) metastases p <0.001 in the last two weeks of life, though only varied between 1% (sternum) and 5% (spine) by site of metastases. Single fraction RT was prescribed more commonly in the last 2 weeks of life (64.2%), compared to individuals who received RT 2-4 weeks (54.5), and >4 weeks (47.9%) before death (p <0.001).
  
  
  CONCLUSIONS
  This population-based analysis found that only 4% of patients with bone metastases received radiation therapy during the last 2 weeks of their life in our population-based, publicly funded program, though it was significantly higher in patients with lung cancer and those with metastases to the spine or extremity. Appropriately, use of multiple fractions palliative RT was less common in patients closer to death.
authors.affiliation: BC Cancer Agency-Centre for the North, Prince George, Canada. Manpreet.Tiwana@bccancer.bc.ca.|University of Northern British Columbia, Prince George, Canada. Manpreet.Tiwana@bccancer.bc.ca.
authors.forename: Manpreet S
authors.initials: MS
authors.lastname: Tiwana
authors.affiliation: BC Cancer Agency-Centre for the North, Prince George, Canada. barnesm@unbc.ca.
authors.forename: Mark
authors.initials: M
authors.lastname: Barnes
authors.affiliation: University of Northern British Columbia, Prince George, Canada. andrewkiralyg@gmail.com.
authors.forename: Andrew
authors.initials: A
authors.lastname: Kiraly
authors.affiliation: BC Cancer Agency-Centre for the North, Prince George, Canada. rolson2@bccancer.bc.ca.|University of Northern British Columbia, Prince George, Canada. rolson2@bccancer.bc.ca.|University of British Columbia, Vancouver, Canada. rolson2@bccancer.bc.ca.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Olson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001859:Bone Neoplasms / Q000532:radiotherapy*; D002170:Canada; D015331:Cohort Studies; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000473:pathology / Q000532:radiotherapy; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology / Q000532:radiotherapy; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis / Q000532:radiotherapy*; D010166:Palliative Care / Q000379:methods*; D011788:Quality of Life; D011878:Radiotherapy / Q000706:statistics & numerical data*; D011879:Radiotherapy Dosage