ASTRO 2015
ASTRO 2015: Technology meets patient care
Dr Brian Kavanagh - University of Colorado Cancer Centre, Aurora, USA
This year the theme is technology meets patient care and I think it’s a very appropriate theme for our specialty in particular. On the one hand, we radiation oncologists are very technology driven, in a sense, we give treatments that are high tech and complex and yet it’s ever so important, nowadays more than ever, to be very much focussed on how patients perceive how they receive the treatment, how well they do from treatment, what are they feeling; how are we doing in terms of meeting their needs for sustaining quality of life, making them comfortable, curing their cancer if possible and being very responsive to their needs. So the theme was selected as a way of illustrating and reinforcing that it’s really all still about the patients, it always has been and always should be. That’s what it’s all about and that’s where our technology should be driving towards - patient care and quality patient care.
What are some of the research highlights of the meeting?
It’s a great question although it’s a hard question because there are so many good things to choose from. I can just mention a few that are on the schedules. There are a number of reports which illustrate how it is that we can use our more sophisticated technology more thoughtfully and more appropriately. For instance, there’s an analysis of one of the largest co-operative group studies ever performed in the treatment of lung cancer, the RTOG-0617 study. That study involved an analysis of how the dose of radiation might or might not affect a patient’s outcome but as a secondary analysis what was considered was what about the level of technology that’s used. So what was observed is that when the more sophisticated technology was used, our newer technology called intensity modulated radiation therapy, or IMRT, when that form of treatment was used relative to results that were achieved when patients were treated with the previous generation of technology the outcomes were better. In particular we cut in half the rate of very severe side effects. The importance to that is that when we are thinking in terms of the value equation the value of healthcare is usually considered traditionally to be some semi-quantitative measure of quality divided by the cost. So it’s sometimes the case where a more expensive treatment might only reduce your value. Here a somewhat more expensive technology, and a little bit more labour intensive, is actually increasing the value of our care because the quality is so much better, the quality in terms of the experience the patient has and also the downstream cost savings that are associated with the reduced rates of hospitalisation and the reduced rates of time in the ICU as a result of our improvements in technology.
The interesting thing about that particular theme, the comparison of IMRT, the most sophisticated treatment we have, versus the previous treatment, was seen not only in that study which was run in North America but also in a study, a fascinating study, that was run at the Tata Memorial Centre in India in Mumbai. Dr Supriya Chopra is presenting some fascinating data that was the result of a study where, once again, a head to head randomised comparison of most sophisticated modern technology versus previous generation technology, in this case specifically in the treatment of patients with cervix cancer who had had a hysterectomy, a very similar outcome – a substantial reduction in the rate of serious toxicities, something that justifies the added labour intensity and the added resource utilisation of the more sophisticated approaches and still adds value and increases value to patients because there is a reduction in hospitalisation and there is a reduction in the costs associated in taking care of downstream side effects. If you can simply avoid them it’s a heck of a lot better.
But that’s not the only way, necessarily, to add value to care. It’s not always necessary to use high technology treatments to improve the value of care and improve the patient quality experience, other studies have done a nice job of showing how can we simply be smarter about using our human resources, if you will. So one of the very nice studies that was presented showed that for patients with head and neck cancer who are receiving radiation therapy who are expected to have a fair amount of side effects in the few weeks after treatment and sometimes even need to be hospitalised, or at least seen in the emergency department, for management of these, if you can take your skilled nurses who help the team take care of patients and have them see the patients a bit more frequently in that critical phase of the final couple of weeks of treatment and the first few weeks afterwards, you can also avoid hospitalisations and reduce emergency department visits. So we think those are excellent ways to be helpful to patients that don’t actually lean only on technology.
Similarly, Dr Paul Read from the University of Virginia is presenting data on a fascinating project that they’ve been conducting there. It was a project that was sponsored by CMMI, the Centre for Medicare and Medicaid Innovation. What their project was all about was a focus on patients who are receiving palliative care. So radiation therapy can play a very important role in the setting where maybe a patient, unfortunately, is past the point where we actually have a curative treatment that’s available but it’s still very important to maintain quality of life and maximise that patient’s time at home with family members and outside of the hospital. So radiation therapy certainly has a very important role in reducing pain in that situation. We can often be very effective in reducing bone pain when cancer has spread to bone; we can reduce other symptoms such as shortness of breath and cough associated with tumours that might be threatening to block an airway. But the bigger message from Paul’s project is that the co-ordinated integration of radiation oncology, medical oncology in the hospice and palliative care team can really pay off to patients in terms of avoiding unnecessary hospitalisations during the last couple of months of life, allowing patients to be much more comfortable and simply feel better and allowing them to have much more family time at home because that is such an important and critical time to maximise the patient’s quality of life. So once again, that’s not so much a use of added technology in the sense of having a very resource intensive high-tech treatment, that’s a matter of us talking to each other and having a teamwork and an integration and intercommunication. So that’s another important emphasis, I think, in some of the lessons we’re learning here is that when we can all put our activities together and co-ordinate our activities for patient care among specialists and among all the healthcare providers who are involved in a cancer patient’s care, we can, most of the time, do a heck of a lot better than if we’re not talking to one another.
Could you comment on the use of therapies such as dexamethasone to improve patients’ overall experience of radiation treatment?
That was another great study; it was done by one of the institutes in Canada and Dr Alysa Fairchild presented an excellent study, a randomised study, where once again the use of a rather inexpensive mode of treatment, an anti-inflammatory, a steroid type anti-inflammatory, was very helpful in the management of cancer patients. In that particular study what was looked at was that, OK, we know that a very efficient and often very tightly compressed course of radiation therapy can do a great job of helping with the pain that a patient may be experiencing if a cancer has spread to the bone. So in that particular study the population of patients who were looked at were receiving a short course of radiation treatment for pain relief. Well, before you get to that state of pain relief it’s also been recognised in the first 48-96 or so hours after treatment there can be a temporary experience of inflammation that is sometimes called a pain flare. It’s annoying and it’s a little bit bothersome and so the idea is can we find something simple that would take that particular unpleasantness off the table. So with the use of a very tried and true, one of our standard medications, dexamethasone, a steroid type anti-inflammatory for just a few days after treatment you can slash that rate in about half. Whereas without that sort of treatment up to maybe 25-30% of the patients would experience a bit of unpleasantness before they started to feel a lot better you can get that rate down to something in the order of 15-18% of patients maybe just having a temporary unpleasantness but then feeling a heck of a lot better after that.
Could you comment on the plans for next year’s meeting?
Sure, the planning for next year’s meeting is already well underway. I can tell you it’s going to be in Boston and it will also be similarly themed about enhancing value and paying a lot of attention to how we improve the quality of patients’ experiences. Although the theme will be worded a little bit differently it’s not going to be that different in emphasis. I’m really looking forward to that. Our President this year will be David Beyer, he is a practitioner who has been in Arizona for quite a long time and he is in a community practice and he’s always been in a community practice and yet has had a very successful career really being an important leader in our organisation because not only is he an extremely smart person and a very aware and talented individual but it’s also very important for our organisation to represent all of our practitioners and all the places where cancer care is delivered. It’s one thing for me, I happen to work in a university setting at the University of Colorado, I have a certain world view based on the place where I practice medicine but that’s only a minority of where medicine is practiced. So we don’t want to just think in terms of places and forums where only at tertiary medical centres can certain things be accomplished. We really want to be broad in our scope of recognising that we need to provide care in a top quality way in every single place where a patient is receiving radiation treatment.
Do you have any final comments?
We are really trying to listen to our patients and we really want to give patients what they need and the best outcomes that they possibly can have in the broadest sense. Radiation is an important part of the curative treatment of a lot of cancers and so we treat patients in their earliest stages and yet it also is an important part of the treatment at lots of other points along the way – at times when the cancer is a little bit progressive and we need to halt it. And later on in the course of treatment for the patients who unfortunately don’t experience a curative result from their therapy we need to be very mindful of how best we can serve patients when we are primarily focussing on symptom relief. Throughout that entire process there’s no better way to learn about what we’re really doing than to talk to patients, understand how they’re feeling and study the patient reported outcomes as opposed to what we think might have happened.
