Beliefs About the Effectiveness of Palliative Radiation Therapy among Patients with Incurable Lung Cancer
Reporter: Gita Suneja, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 30, 2012
Presenter: Aileen Chen, MD, MPP
Affiliation: Brigham and Women's Hospital and Dana-Farber Cancer Institute
- Metastatic lung cancer is almost always incurable, and radiation therapy is a mainstay of palliative treatment.
- Providers are often overly optimistic in communicating prognosis and anticipated treatment benefits to patients and families.
- Even when information is accurately communicated, patients may have inaccurate expectations.
- The purpose of this study was to assess patient understanding of the goals of palliative radiation therapy for incurable lung cancer.
- Patients were identified using the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) dataset.
- The CanCORS is an NCI-funded multi-center prospective cohort study covering 5 geographic regions, 10 Veterans Administration sites, and 5 large Health Maintenance Organizations.
- The cohort for this study included adults > 21 with lung cancer diagnosed from 2003-2005.
- Inclusion criteria included a diagnosis of incurable lung cancer defined as stage IIIB with malignant effusion (stage IV in current AJCC staging system) or stage IV. Patients also need to have completed, currently undergoing, or scheduled to have radiation therapy at the time of enrollment.
- Of a total 2,044 patients in the CanCORS database with stage IIIB and IV lung cancer, 384 met inclusion criteria and were surveyed.
- Medical record abstraction was performed from 3 months pre-diagnosis to 15 months post-diagnosis. Records from all providers involved in cancer care were reviewed.
- Trained telephone interviewers surveyed patients 4 to 7 months after diagnosis. If patients were too sick to be interviewed, surrogates were interviewed in their place.
- Patients were asked: "After talking with your doctor about radiation therapy, how likely did you think it was that radiation would (1) help you with problems from your cancer, (2) help you live longer, and (3) cure your cancer?"
- Answer choices included "very likely, somewhat likely, a little likely, not at all likely, or did not know."
- The cohort consisted of 384 patients. 90% were stage IV, 82% had non-small cell histology, 80% were < 75 years of age, 60% were male, 70% were white, and 21% had less than high school education. 26% of patients required a surrogate to respond to survey questions.
- When asked how likely it is that radiation therapy will help with problems from cancer, 67% of patients/surrogates responded "very or somewhat likely."
- When asked how likely it is that radiation therapy will help the patient live longer, 78% of patients/surrogates responded "very or somewhat likely."
- When asked how likely it is that radiation therapy will cure the patient, 45% of patients/surrogates responded "very or somewhat likely."
- Overall, 36% of patients/surrogates had accurate expectations, and 64% had inaccurate expectations.
- On multivariate analysis, factors associated with inaccurate expectations were non-white race. African-American patients/surrogates had 1.5 odds of having inaccurate expectations and other non-whites had 3.3 times the odds. Patients too sick to complete the survey were less likely to believe that radiation therapy might be curative with odds ratio 0.5.
- Most patients receiving radiation therapy for incurable lung cancer believe that palliative treatment will help them.
- Many do not understand that radiation therapy is not likely to cure their cancer.
- Non-white patients were more likely to have inaccurate beliefs, and very sick patients were less likely to have inaccurate beliefs.
- Patients with unrealistic expectations are less able to make informed decisions about end-of life care and may pursue more intensive therapies.
- These findings suggest a need to improve communication strategies surrounding treatment benefits in metastatic lung cancer.
- This very important study is the first of its size and scope to address the issue of patient expectations of palliative radiotherapy.
- The study found that patients are more likely to have inaccurate expectations of the radiation therapy than to have accurate expectations. Non-white patients are at higher risk of having inaccurate expectations.
- A companion study found similar results for expectations of palliative chemotherapy.
- Limitations of the study include selection bias due to the inability to survey patients who declined to participate or were deceased by the time the survey was administered. Furthermore, the survey did not ascertain reasons for inaccurate expectations and whether they were physician-related factors, patient-related factors, or other reasons for inaccurate expectations.
- Oncologists routinely deal with end-of-life care. Medical schools and residency programs teach students how to break bad news, however limited teaching is available for management of patient expectations.
- A fine balance must be struck between giving the incurable patient hope for a high quality of life, while not delivering inaccurate information about chances for cure.
- While palliative radiation therapy can be effective at controlling symptoms and improving quality of life, it is not curative.
- Furthermore, overly intensive treatment can reduce patient quality of life and lead to financial strain for patients and families.
- This elegant study highlights a major discrepancy in expectations for patients with incurable lung cancer, and additional research is needed to identify underlying reasons for this discrepancy. Once we have a better understanding of the scope of the problem, we can begin to develop solutions for improved communication to patients and families about prognosis from incurable cancer.