Some published reports indicate that radiation therapy (RT) may be overutilized in adult patients at end of life (EOL), defined as within 30 days of death. With regard to the pediatric population, very little data exist evaluating the use of RT at EOL.
Joseph Panoff, MD, MA, Nikesh Shah, BS, Michael Scott, MD, MBA, Peter Johnstone, MD, FACR; Indiana University Health Proton Therapy Center; Department of Radiation Oncology, University of Miami
Objective: Some published reports indicate that radiation therapy (RT) may be overutilized in adult patients at end of life (EOL), defined as within 30 days of death. With regard to the pediatric population, very little data exist evaluating the use of RT at EOL. Furthermore, since pediatric cancer may be cured, even when metastatic, current pediatric clinical practice is even more aggressive. Complicating the issue are the geographic and technical complexities surrounding the very select population of children receiving proton therapy (PrT). We sought to compare pediatric practice data for conventional RT and PrT, specifically evaluating death rate within 30 days.
Patients and Methods: The records of the Indiana University Health Proton Therapy Center (IUHPTC) and University of Miami Radiation Oncology Department (UM) were reviewed for all patients receiving RT at age < 21 years between June 1, 2000 and June 1, 2013. Of these patients, analysis was made of patients not completing prescribed courses of RT and of patients dying within 30 days of receiving RT. Comparison was made of differences between practice data for PrT and conventional RT.
Results: At IUHPTC, 382 patient courses were prescribed to 356 children between June 2008 and June 2013. Two children did not complete their courses (0.5%). After January 1, 2010, when IUHPTC data submission became required for facility accreditation, only those same 2 children of 272 treated died within 30 days (0.74%). These data were no different for children (ages < 12 yr) versus adolescents/young adults (ages 13–21 yr) because of limited events. At UM, data were available from January 1, 2000 through June 1, 2013: 464 courses of RT were delivered to 425 children. Nine children did not complete their courses (1.9%), and nine died within 30 days (1.9%). Neither the number of patients who did not complete treatment nor the 30-day death rates for PrT and conventional RT were significantly different (Fisher’s exact test, P = .21).
Conclusions: The issue of when to truncate RT for children at EOL is far more complex than in adults, especially since certain metastatic pediatric tumors are curable by RT. When comparing data from two large academic centers that utilize PrT and conventional RT, we found that there was no difference in the use of PrT when compared with RT for EOL. These results were evident, despite extreme patient selection inherent in the use of PrT.