Rapid Response Radiotherapy Program, Department of Radiation Oncology, Toronto-Sunnybrook Regional Cancer Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4 N 3M5, Canada. firstname.lastname@example.org
The rapid response radiotherapy program (RRRP) at Toronto-Sunnybrook Regional Cancer Center (TSRCC) provides quick access to palliative radiotherapy for patients with a life expectancy of less than 12 months. Patients then return to their referring physician for continued oncologic management. After the initial RRRP consultation, we fax an interim consultation report to the referring physician. The purpose of this study was to assess how useful referring physicians perceive this interim report and whether this report needs to be modified to meet their information needs.
Physicians who referred patients to the RRRP and who were faxed an interim consultation report were identified over a 4-month period. These physicians were then faxed a questionnaire that asked how useful the interim report was in patient management, about their satisfaction with the information provided, to critique the report format, and whether the RRRP physician and nurse were easily accessible by telephone.
Forty physicians referred patients to the RRRP clinic over the 4-month study period. The response rate to our survey was 58% (23/40). The vast majority of physicians (95%) stated that the interim consultation report was useful in patient management. They felt that treatment details were adequately discussed in the report. The report format was perceived to be clear and concise. Referring physicians wished to be informed about any medication changes. RRRP physicians and nurse were perceived to be easily accessible by telephone if needed.
Results showed that referring physicians found the faxed interim consultation report useful in patient management. Suggestions were made on how to improve the report, and they will be used to further enhance physician communication and ultimately patient care.
This paper describes the development of the Rapid Response Radiotherapy Program and evaluates the continuing medical education (CME) series, in the form of multidisciplinary monthly Radiation Oncology Palliative Care Rounds at the Toronto Sunnybrook Regional Cancer Centre.
Palliative care rounds were initiated by the multidisciplinary committee in September, 1998. From January, 2000, to June, 2002, attendees used a standard 5- point Likert rating scale to conduct formal evaluations.
A total of 203 evaluation forms examining 20 rounds have been collected. Findings indicated that 86.8, 96.0, 87.1, and 90.8% of participants thought the material of the presentation was relevant to their practice, interesting, and instructional. Overall 90.1% of the respondents highly rated the grand rounds (rating of 4 or 5).
The grand rounds are an effective CME activity at our hospital.
The Palliative Performance Scale (PPS) was developed by the Victoria Hospice Society in 1996 to modernize the Karnofsky Performance Scale. Currently, it is being used to measure palliative patient performance status in a variety of settings. Despite its widespread use, only one study has examined the inter-rater reliability of the PPS.
To examine the inter-rater reliability of the PPS in measuring performance status in patients seen in an outpatient palliative radiation oncology clinic
Performance status for 102 consecutive patients was assessed by an oncologist (MD), a radiation therapist (RT), and a research assistant (RA) in the Rapid Response Radiotherapy Program at the Odette Cancer Centre in Toronto, Ontario, Canada. Raters' scores were analyzed for correlation and compared to evaluate the inter-rater reliability of the PPS tool.
Excellent correlation was found between the scores rated by the MD and RA (r = 0.86); good correlation was observed between scores rated by the MD and RT (r = 0.69) and the RT and RA (r = 0.77). Scores between all three raters, as well as between rater pairs, were also found to have good reliability as measured by the Chronbach's alpha coefficient. Significant results were obtained for the range of PPS scores in which the majority of our patients fell: 40-80%.
PPS was shown to have good overall inter-rater reliability in an outpatient palliative setting, but more research is needed to establish the validity and reliability of the tool in a variety of different palliative settings.
The primary objective of this study was to determine whether there is a relationship between the severity of pretreatment pain and response to palliative radiotherapy (RT) for painful bone metastases.
The database for patients with bone metastases seen at the Rapid Response Radiotherapy Program at the Odette Cancer Center from 1999 to 2006 was analyzed. The proportion of patients with mild (scores 1-4), moderate (scores 5-6), or severe (scores 7-10) pain at baseline who experienced a complete response, partial response, stable response, or progressive response after palliative RT was determined according to International Bone Metastases Consensus definitions.
During the 7-year study period 1,053 patients received palliative radiation for bone metastases. The median age was 68 years and the median Karnofsky performance status was 70. Of the patients, 53% had a complete or partial response at 1 month, 52% at 2 months, and 54% at 3 months post-RT.
There was no significant difference in terms of the proportion of responders (patients with complete or partial response) and nonresponders in terms of painful bone metastases among patients presenting with mild, moderate, or severe pain. Patients with moderate pain should be referred for palliative RT.
To prospectively assess patient-rated symptoms in patients with brain metastases treated with whole brain radiotherapy, these patients were asked to rate their symptoms on the Edmonton Symptom Assessment Scale (ESAS) before, and 1, 2, 4, 8, and 12 weeks following the radiation treatment. ESAS evaluates pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, sense of well-being, and shortness of breath on a scale of 0-10 (0=absence of symptom and 10=worst possible symptom). Patients with a language barrier or significant cognitive impairment were excluded. The mean difference of ESAS symptoms at each follow up were compared with baseline and P or =10% over the last 6 months). All patients were prescribed dexamethasone at varying doses during radiotherapy. The dose fractionations were 20 Gy in 5 fractions, 138 (81%); 30 Gy in 10 fractions, 7 (4%); and others, 25 (15%). The baseline mean +/- SD for ESAS scores were: pain 2.4 +/- 2.8, fatigue 5.3 +/- 2.8, nausea 1.3 +/- 2.2, depression 2.8 +/- 2.7, anxiety 3.6 +/- 3.0, drowsiness 3.5 +/- 2.9, appetite 3.0 +/- 3.2, sense of well-being 3.8 +/- 2.7, and shortness of breath 2.3 +/- 2.5. For the entire cohort, after the delivery of palliative radiotherapy for brain metastases, there were statistically significant deteriorations in the mean differences from the baseline for the following ESAS domains: fatigue 1.0 to 1.8; drowsiness 1.2 to 1.8; and appetite 2.2 to 2.4. The data demonstrate that certain parameters of quality of life worsen after whole brain radiotherapy.
Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada M4N 3M5. email@example.com
The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization's "analgesic ladder" approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain.
The aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI.
All patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, "weak" opioids, and "strong" opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearson's r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors.
One thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P
The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating=0], mild [rating=1-4], moderate [rating=5-6] or severe [rating=7-10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28-95) and the median Karnofsky Performance Status was 70 (range 10-100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.