A survey of patterns of practice on palliative radiation therapy for bone metastasis in Korea

Abstract

Purpose

The aim of this study was to understand the practice patterns of palliative radiation therapy for bone metastasis in Korea among Korean radiation oncologists by survey and to determine the decision factors affecting the prescription of radiation therapy fractionation schedules.

Methods

An Internet-based survey was performed from October 5 to October 23, 2009, among 177 active full members of the Korean Society for Radiation and Oncology (KOSRO). The survey questionnaire included general information about the respondent, three types of clinical scenario, depending on the life expectancy of the patients, and the decision factors that affected the prescription of a radiation therapy schedule.

Results

The most prescribed schedule was 30 Gy in 10 fractions regardless of the life expectancy of the patient. Also, it was found that a single fraction was seldom prescribed routinely in Korea. An increasing number prescribed fewer than 10 fractions as the life expectancy shortened; however, the prescription rate of a single fraction was still low. The general performance (and/or accompanying diseases) of patients and the life expectancy were the most considered factors in deciding the prescription of radiation therapy.

Conclusions

Despite the abundant evidence supporting the equivalence of single- and multi-fraction radiation therapy, still, most Korean radiation oncologists continue to prescribe multi-fraction schedules depending on the general performance and life expectancy of the patients. Thus, we confirmed that there was a gap between evidence and practice, and treatment prescriptions can be strongly affected by decision factors other than published literature results.

Introduction

Bone metastasis is one of the major causes of cancer pain, which can be alleviated effectively by radiation therapy (RT). Approximately 50–80 % of patients who received RT show relief from pain, and 20–50 % of patients experienced complete pain relief (Chow et al. 2007, 2012; Sze et al. 2003; Wu et al. 2003). Palliative RT for pain relief has been applied with various radiation doses and fractionation schedules, from a single fraction to multiple fractions over 2 weeks or longer. The single fraction has advantages in terms of patient convenience and cost-effectiveness, with the short period of treatment (Chow et al. 2012; Wu et al. 2003), and multiple fractions have the advantages of improved treatment responses, with increased radiation doses, and lower rates of recurrence.

There have been many studies investigating the optimal RT dose fractionation schedule for pain palliation. Several prospective randomized clinical trials have been carried out since the late 1990s to compare the effectiveness of palliation and adverse side effects between a single fraction and multiple fractions, and they have shown that the pain palliation effect was comparable between a single fraction and fractionated schedules (Anonymous 1999; Cole 1989; Gaze et al. 1997; Hartsell et al. 2005; Kagei et al. 1990; Madsen 1983; Nielsen et al. 1998; Price et al. 1986; Steenland et al. 1999; Kaasa et al. 2006; Majumder et al. 2012). Although there is abundant evidence about the effectiveness of single-fraction RT, it is still underused in international patterns of practice (Fairchild et al. 2009). The American Society for Radiation Oncology published evidence-based guideline for bone metastasis palliative RT in 2011 and suggested that single- and multi-fraction RT are within the standard of care (Lutz et al. 2011).

However, because there has been no systematic study on the standard RT for the patients with bone metastasis in Korea, there is a need to determine the optimal palliative RT schedule for patients according to life expectancy, fully considering the adequacy of treatment effect, accessibility, and the expense of treatment. Before finding the optimal RT schedule, understanding the current pattern of practice in our country was first required. Thus, this study was aimed at understanding practice patterns in palliative RT for bone metastasis in Korea among Korean radiation oncologists using a survey and to determine the decision factors that affect the prescription of RT fractionation schedules.

Methods and materials

An Internet-based survey was performed from October 5 to October 23, 2009, among 177 active full members of Korean Society for Radiation and Oncology (KOSRO); of them, 88 members replied to the questionnaire (response rate 49.7 %). Characteristics of the respondents are summarized in Table 1. To ensure the validity of this survey, a pilot survey had been performed with six radiation oncologists before the actual survey.

Table 1.

Respondent characteristics

Characteristics	n (%)
Gender
Male	60 (68.2)
Female	28 (31.8)
Age (years)
30–39	26 (29.5)
40–49	44 (50.0)
≥50	18 (20.5)
Practice (years)
<3	10 (11.4)
3–10	23 (26.1)
10–20	38 (43.2)
≥20	17 (19.3)
Practice type
National University	18 (20.5)
Private University	61 (69.3)
General Hospital	8 (9.1)
Other	1 (1.1)
Daily average number of patients for treatment
<50	33 (37.5)
50–100	25 (28.4)
100–150	9 (10.2)
150–200	1 (1.1)
>200	20 (22.7)
Average percentage of palliative RT
<25 %	51 (58.0)
25–50 %	36 (40.9)
50–75 %	1 (1.1)
Period from referral to start of RT (days)
1	70 (79.5)
2	17 (19.3)
3	1 (1.1)

RT radiation therapy

The survey questionnaire included general information about the respondent, three types of clinical scenario, depending on the life expectancy of the patients, and the factors that affected the decision on RT prescription (“Appendix”). The questionnaire was presented with the following three case scenarios according to the state of life expectancy of the patients: good prognosis (case 1: breast cancer), a good performance status with a diagnosis of localized spine metastasis after 3 years of treatment; intermediate prognosis (case 2: small cell lung cancer), a good performance status with a diagnosis of liver and intra-abdominal lymph node metastasis and localized spine metastasis after 1 year of treatment; and poor prognosis (case 3: non-small cell lung cancer), a poor performance status with a diagnosis of multiple bone metastases while being treated for mediastinal lymph node metastasis and liver metastasis after 1 year and 8 months of treatment. Respondents were asked to reply regarding the fraction size and fraction numbers for RT in the three cases.

Statistical analysis was performed using the PASW Statistics software (ver. 18.0; SPSS Inc., Chicago, IL, USA). The Chi squared test was used in comparisons between the groups. A P value lower than 0.05 was considered to indicate statistical significance.

Results

Radiation therapy prescription

Among the 88 respondents, the numbers of radiation oncologists who would recommend palliative RT to cases 1, 2, and 3 were 86 (97.7 %), 80 (90.9 %), and 84 (95.5 %), respectively. Table 2 summarizes the RT prescription in each case. The vast majority of the respondents replied that they would prescribe RT in over 10 fractions for case 1 (80, 93.0 %) and case 2 (71, 88.8 %). However, for case 3, having the worst prognosis, 44 (52.4 %) respondents replied that they would prescribe RT in over 10 fractions. For cases 1 and 2, 30 Gy in 10 fractions was most commonly prescribed, by 42 (48.8 %) and 61 respondents (76.3 %), respectively. On the other hand, for case 3, 30 Gy in 10 fractions and 20 Gy in 5 fractions were equally common, in 31 (36.9 %) and 29 (34.5 %) respondents, respectively. For case 1, two respondents replied that they would use a single-fraction high-dose stereotactic body RT, delivering 18 and 16 Gy, respectively. No respondent prescribed a single fraction for case 2, while only one prescribed 8 Gy in a single-fraction RT for case 3. Figure 1 shows the distribution of prescription patterns for each case.

Table 2.

Radiation therapy prescription for each case scenario

Case (prognosis)	Response employing RT	Dose fractionation, n (%)		Single fraction	Most common regimen (Gy/fx)	Range (Gy/fx)
	n (% in 88 members)	<10 fx	≥10 fx	n (%)
1 (good)	86 (97.7)	6 (7.0)	80 (93.0)	2 (2.0)	30/10	18/1–50/25
2 (intermediate)	80 (90.9)	9 (11.3)	71 (88.8)	0 (0.0)	30/10	5/4–45/25
3 (bad)	84 (95.5)	40 (47.6)	44 (52.4)	1 (1.2)	30/10	8/1–50.4/28

RT radiation therapy, fx fractions

Fig. 1.

Distribution of radiation therapy prescription pattern for case 1 (a), case 2 (b), and case 3 (c). Circle size (and number in the each circle) represents the number of responses for each prescription schedule

In the analysis of the characteristics that affected the respondents’ prescriptions in each case, no significant factor was seen for cases 1 or 2. For case 3, RT with less than 10 fractions seemed to be preferred with increased patient flow in the respondents’ department. The respondent numbers who would prescribe RT of less than 10 fractions were 9 (29.0 %), 16 (48.5 %), and 15 (75.0 %) in cases when the daily average numbers of patients receiving RT—for any purpose—were fewer than 50, 50–150, and more than 150, respectively (Table 3).

Table 3.

Respondent characteristics affecting the prescription of 10 or more fractions

Characteristics	Case 1, n (%)			Case 2, n (%)			Case 3, n (%)
	<10 fx	≥10 fx	P value	<10 fx	≥10 fx	P value	<10 fx	≥10 fx	P value
Gender
Male	4 (6.8)	55 (93.2)	0.916	7 (13.0)	47 (87.0)	0.485	26 (44.8)	32 (55.2)	0.444
Female	2 (7.4)	25 (92.6)		2 (7.7)	24 (92.3)		14 (53.8)	12 (46.2)
Age (years)
30–39	2 (8.0)	23 (92.0)	0.953	4 (17.4)	19 (82.6)	0.506	16 (61.5)	10 (38.5)	0.178
40–49	3 (7.0)	40 (93.0)		3 (7.7)	36 (92.3)		19 (44.2)	24 (55.8)
≥50	1 (5.6)	17 (94.4)		2 (11.1)	16 (88.9)		5 (33.3)	10 (66.7)
Practice (years)
<10	2 (6.3)	30 (93.8)	0.839	6 (20.0)	24 (80.0)	0.055	19 (57.6)	14 (42.4)	0.142
≥10	4 (7.4)	50 (92.6)		3 (6.0)	47 (94.0)		21 (41.2)	30 (58.8)
Practice type
Private university	5 (8.5)	54 (91.5)	0.42	7 (13.0)	47 (87.0)	0.485	28 (47.5)	31 (52.5)	0.964
Others	1 (3.7)	26 (96.3)		2 (7.7)	24 (92.3)		12 (48.0)	13 (52.0)
Average number of patients per day
<50	0 (0.0)	32 (100)	0.051	2 (6.7)	28 (93.3)	0.08	9 (29.0)	22 (71.0)	0.006
50–150	5 (15.2)	28 (84.8)		2 (6.7)	28 (93.3)		16 (48.5)	17 (51.5)
>150	1 (4.8)	20 (95.2)		5 (25.0)	15 (75.0)		15 (75.0)	5 (25.0)
Average % of palliative RT
<25 %	1 (2.0)	49 (98.0)	0.033	7 (14.3)	42 (6.5)	0.28	23 (46.9)	26 (53.1)	0.883
≥25 %	5 (13.9)	31 (86.1)		2 (85.7)	29 (93.4)		17 (48.6)	18 (51.4)
Period from referral to start of RT
1 day	4 (5.9)	64 (94.1)	0.439	5 (7.7)	60 (92.3)	0.058	33 (49.3)	34 (50.7)	0.551
≥2 days	2 (11.1)	16 (88.9)		4 (26.7)	11 (73.3)		7 (41.2)	10 (58.8)

fx fractions, RT radiation therapy

Decision factors for the radiation therapy schedule

Regarding the important decision factors that would affect the prescription of RT schedules (Table 4), the most frequent answers were the general performance (72.7 %) and the life expectancy of the patients (69.3 %). Additionally, the expectation of efficacy (23.9 %) and fear for complications of RT (18.2 %) followed, while the policy of their department (including financial considerations) (6.8 %), training habits (4.5 %), conveniences (3.4 %), and age of the patients (1.1 %) were low.

Table 4.

Important decision factors affecting the radiation therapy schedule (multiple choices)

Factors	Response (%)
General performance status (accompanying disease)	64 (72.7)
Life expectancy of the patient	61 (69.3)
Complications of radiation therapy	16 (18.2)
Convenience	3 (3.4)
Expectation of efficacy (chosen schedule is known to have better effectiveness than others)	21 (23.9)
Policy and situation of department (including financial considerations)	6 (6.8)
Training habits	4 (4.5)
Patient age	1 (1.1)

Discussion

A survey was performed to understand the practice patterns of palliative RT for bone metastasis in Korea and to determine the decision factors affecting the RT fractionation prescriptions. The most commonly prescribed schedule was 30 Gy in 10 fractions regardless of the life expectancy of cases. Also, it was found that a single fraction was rarely prescribed routinely. The number of respondents who would prescribe RT in fewer than 10 fractions did increase as the life expectancy shortened; however, the rate of prescribing a single fraction was still very low. The general performance (and/or accompanying diseases) of the patients and their life expectancy were the most important decision factors considered in determining the RT prescription, and RT in 10 or more fractions was mostly prescribed if the life expectancy seemed reasonably long, which appears to be the general pattern of practice in Korea for palliative RT of bone metastases. Prescription of RT in fewer than 10 fractions was preferred as patient flow increased at the respondent’s hospital, suggesting that efficient administration of medical resources was also a consideration.

Since the 1990s, survey research on palliative RT for bone metastasis has been conducted in several countries, including Europe, Canada, Australia, and USA (Bradley et al. 2007; Chow et al. 2000; Adamietz et al. 2002; Ben-Josef et al. 1998; Roos 2000; Maher et al. 1992; Duncan et al. 1993; Crellin et al. 1989). In 2009, an international pattern of practice survey was published, conducted by members of three global radiation oncology professional organizations (American Society for Radiation Oncology, Canadian Association of Radiation Oncology, and Royal Australian and New Zealand College of Radiologists). In Europe and the United Kingdom, single-fraction RT was the most common treatment schedule. On the other hand, 20 Gy in 5 fractions in Canada, Australia, and New Zealand and 30 Gy in 10 fractions in USA and Asia were the most common regimens (Fairchild et al. 2009). Nakamura et al. (2012) also reported survey results of current patterns of practice in Japan, and a schedule of 30 Gy in 10 fractions was most common, which is the same finding in Korea from our study. These studies indicated regional and national differences in the treatment regimen. Most countries—other than the European region—still typically use multi-fraction RT. However, European radiation oncologists have been using a single-fraction regimen more frequently. Respondents who practiced in university hospital settings in Western countries preferred a single fraction, apparently because of their readiness to follow the results of randomized clinical trials. Similarly, respondents working in university hospital settings in Korea tended to prefer smaller number of fractions although medical resource utilization was apparently the major reason for considering a short treatment. However, the medical environment in Japan and Korea, where the reimbursement is affected by the number of RT fractions, seemed to have an influence on the prescription of multiple fractions. Lievens et al. (2000) also reported that reimburse systems seemed to affect RT practice: a fee-for-service reimbursement, which was frequently in Germany and Switzerland and also utilized in Korea, induced a longer fractionation schedules than budget and case payment, which was common in Spain, the Netherlands, and the United Kingdom. Furthermore, similar to Japanese radiation oncologists having a preference to learn from U.S medical resources (Nakamura et al. 2012), Korean radiation oncologists are often affected by the practice of United States, which also might influence similar pattern of practice as those countries.

Our study has certain limitations. First, an Internet-based survey could have failed to fully reflect the specific circumstances of clinical practice. We utilized survey using the questionnaire instead of analysis of the patients’ data. We think that our survey questionnaire with clinical scenarios could be sufficiently useful as reference cases to investigate the pattern of practice, because it fully considered significant factors to determine treatment scheme. But, we think that analysis of the patients’ data could provide more reliable findings compared to survey using questionnaire to overcome this limitation. So, further study analyzing the patient data would be needed. Second, to investigate the patterns of practice in Korea, we modified and developed the questionnaire from the survey questions in previous studies that were conducted in Western countries. Since there may have been some cultural differences in the decision-making process, our validated questionnaire would be optimal to understand the pattern of care for bone metastasis in Korea. In future studies, appropriate methodologies should be developed to fully consider this. Also, the case scenarios should be specified with respect to prognosis in various clinical settings in more detail, to further investigate what the effective RT is. These additional studies would help to provide firmer and clearer evidence-based treatment guidelines.

Despite the abundant evidence supporting the equivalence of single- and multi-fraction RT, most Korean radiation oncologists continue to prescribe multi-fraction schedules depending on the general performance and life expectancy of the patients. Thus, we confirmed that there was a gap between the evidence and the practice, and the treatment prescription was strongly affected by decision factors other than the published evidence.

Appendix: Survey

General information

1. Years of completion of radiation oncology specialty training

   • ❏
     <3 years
   • ❏
     3–10 years
   • ❏
     10–20 years
   • ❏
     More than 20 years
2. Type of practice

   • ❏
     National University
   • ❏
     Private University
   • ❏
     General Hospital
   • ❏
     Other (private practice, etc.)
3. Specialty (2 choices)

   • ❏
     Breast cancer
   • ❏
     Lung cancer
   • ❏
     Head and Neck cancer
   • ❏
     Gastrointestinal cancer
   • ❏
     Brain tumor
   • ❏
     Genitourinary cancer
   • ❏
     Pediatric malignancy
   • ❏
     Lymphoma, leukemia
   • ❏
     Urological cancer
   • ❏
     Other (including benign disease)
4. Current geographic area of practice

   • ❏
     Seoul
   • ❏
     Gyeonggi-do
   • ❏
     Chungcheongbuk-do
   • ❏
     Chungcheonnam-do
   • ❏
     Gyeongsangbuk-do
   • ❏
     Gyeongsangnam-do
   • ❏
     Jeollabuk-do
   • ❏
     Jeollanam-do
   • ❏
     Gangwon-do
   • ❏
     Jeju-do

• 5.
  Average number of patients receiving radiation therapy per day

  • ❏
    <50
  • ❏
    50–100
  • ❏
    100–150
  • ❏
    150–200
  • ❏
    More than 200

• 6.
  Average percentage of palliative radiation therapy in practice of the department

  • ❏
    <25 %
  • ❏
    25–50 %
  • ❏
    50–75 %
  • ❏
    75–100 %

• 7.
  Average percentage of palliative radiation therapy in practice of the respondent

  • ❏
    <25 %
  • ❏
    25–50 %
  • ❏
    50–75 %
  • ❏
    75–100 %

• 8.
  Approximate period from referral to start of radiation therapy

  • ❏
    On that day (1 day)
  • ❏
    2 days
  • ❏
    3 days
  • ❏
    More than 4 days

Choosing radiation therapy schedule with hypothetical case scenarios

Case 1

A 55-year-old woman was diagnosed with stage I (pT2N0) breast cancer after a mastectomy 3 years ago, followed by tamoxifen. She reports recently developed thoracic back pain. Bone scan reveals intense uptake in the T6 and 7 spine. On plain X-ray, bone metastasis is seen. Spine MRI shows no evidence of spinal cord compression. She does not complain of radicular pain. There are no other sites of distant metastases. She took a narcotic analgesic due to the symptoms above, but the pain did not subside.

1. As a part of the management of this patient, would you recommend external beam radiation therapy to the painful site for this patient?

   • ❏
     Yes (go to Question 1-1)
   • ❏
     No (go to Question 1-2)

   • 1-1.
     What total dose and fractionation schedule would you prescribe?
     ( ) Gy/( ) fraction(s)
   • 1-2.
     If you would not implement radiation therapy, please mention a treatment option that you would consider.
     (                                                     )

Case 2

A 64-year-old woman was treated with chemoradiation a year ago for limited stage small cell lung cancer and followed. During follow-up, she complained of pain in the lumbar spine, which developed recently. Her bone scan shows increased uptake at the L3 spine, and on spine MRI, there was no cauda equina or thecal sac compression. Abdominal CT scan revealed multiple metastases in the liver and abdominal lymph nodes. She had an ECOG performance status of 1. Although she took a narcotic analgesic because of the symptoms above, the analgesic effect was negligible.

• 2.
  As a part of the management of this patient, would you recommend external beam radiation therapy to the painful site for this patient?

  • ❏
    Yes (go to Question 2-1)
  • ❏
    No (go to Question 2-2)

  • 2-1.
    What total dose and fractionation schedule would you prescribe?
    ( ) Gy/( ) fraction(s)
  • 2-2.
    If you would not implement radiation therapy, please mention a treatment option that you would consider.
    (                                                     )

Case 3

A 55-year-old man was diagnosed with stage IIIA non-small-cell lung cancer 2 years ago and was treated with radical surgery and followed. 3 months ago, he was diagnosed with mediastinal lymph node and liver metastases and received systemic chemotherapy. On a bone scan, because of a chief complaint of recently developed general weakness and pelvic pain, multiple bone metastases in the thoracic spine, lumbar spine, and right iliac crest were seen. On physical examination, he had tenderness on pressure over the right iliac crest. His performance status is ECOG 3, determined by poor oral intake, general weakness, and pain.

• 3.
  As a part of the management of this patient, would you recommend external beam radiation therapy to the painful site for this patient?

  • ❏
    Yes (go to Question 3-1)
  • ❏
    No (go to Question 3-2)

  • 3-1.
    What total dose and fractionation schedule would you prescribe?
    ( ) Gy/( ) fraction(s)
  • 3-2.
    If you would not implement radiation therapy, please mention a treatment option that you would consider.
    (                                                     )

• 4.
  Please choose the important factors that affected your decision regarding the radiation therapy prescription in cases 1–3 (multiple choices).

  • ❏
    Patient age
  • ❏
    General performance status (accompanying diseases) of patient
  • ❏
    Life expectancy of patient
  • ❏
    Complications of radiation therapy
  • ❏
    Convenience
  • ❏
    Expectation of efficacy
  • ❏
    Policy and situation of your department (including financial considerations)
  • ❏
    Training habits