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The Availability of Advanced Radiation Oncology Technology Within VHA Radiation Oncology Centers
The VHA is the primary care provider for 20.4% of the more than 21.9 million military veterans.1 Surveys report that over a lifetime, an estimated 28.4% of U.S. veterans will receive some measure of their health care from the VHA.2 An estimated 40,000 new cancer cases are diagnosed each year from these veterans, resulting in a minimum of 175,000 veterans receiving cancer care in VHA facilities.3 The 39 VHA facilities currently with onsite radiation oncology practices annually provide radiation therapy to about 20,000 veterans (Figure 1).
Nationally, tumor control and toxicity outcomes have each improved over recent decades as advances have occurred in imaging, radiation treatment planning, and equipment for the delivery of radiotherapy.4 The VHA has kept pace with these technological advancements to the point where image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy (SBRT) are widely available at VHA centers. Additionally, all active VHA radiation oncology centers have earned accreditation from the American College of Radiology, while 3 new centers are in the process of gaining accreditation.
When technologies deemed to be medically necessary are not available onsite, these treatments are made available to veterans through referral to other VHA or non-VHA centers. Here, the authors present the results of a survey of VHA-based radiation oncologists to evaluate onsite availability of various radiation technologies.
Methods
The VHA Palliative Radiotherapy Task Force constructed an online survey and sent it to the 82 radiation oncologists practicing at the 38 VHA radiation oncology centers that were active at the time. After emailing the survey,follow-up phone calls were made to maximize response rates. The survey was conducted during the months of May and June of 2014.
In this survey, all 82 VHA radiation oncologists were queried on the availability of advanced radiation delivery technologies including IGRT, IMRT, and SBRT at their facilities. The authors also surveyed for presence of brachytherapy (BT) programs, stereotactic radiosurgery (SRS), and cone-beam computed tomography (CBCT). Information was collected regarding the extent to which physicians can treat cases requiring SRS and/or SBRT onsite vs through referral to another facility for treatment. These data were gathered from a survey conducted in conjunction with a larger survey on the practice and patterns of care in the treatment of patients with brain metastases within the VHA.5,6 The data presented here apply to radiation therapy in general and are not limited to the treatment of brain metastases.
Results
The overall response rate was 76% (62 of 82 radiation oncologists). At the time of the survey, 90% (34 of 38) of active VHA radiation oncology treatment facilities were represented. However as of May 2016, there are 40 active VHA radiation oncology centers. Figure 2 describes the availability of various treatment delivery systems. The data demonstrated 100% availability of IMRT. Respondents reported onsite availability of IGRT at 91%, CBCT at 74%, and SBRT at 53%. Treatment technologies that were not as widely available at VHA facilities with inherent radiation oncology practices included SRS at 29% and BT at 21%. For cases requiring SRS, 69% (40 of 58) of respondents who answered this question indicated that they refer patients to other VHA radiation oncology centers or VHA contracted private entities. This report is limited by the following factors:
- A narrow scope of practices was surveyed. The survey was solely sent to VHA physicians at 38 active VHA radiation oncology centers out of 144 VHA hospitals. Therefore the practices at VHA medical centers without active VHA radiation was not acquired with this survey.
- This survey only addresses availability of these newer treatment technologies, not their actual use, in treating cancers predominant within the VHA.
- Literature comparison in this report is based on current use of these technologies for some of the reports cited, rather than availability as this report reflects. As such, direct comparisons could be misleading.
Discussion
Although the total number of veterans has been decreasing in recent years, the number of veterans enrolling into VHA-related programs has been increasing and is expected to expand increase further in years to come.1,2 It is important for radiation oncologists to keep pace with new technologies to ensure their patients have access to the best possible treatments.
Advances in radiation oncology have allowed radiotherapy to evolve from the 2-dimensional treatments of the 1950s to the 1980s, to more targeted treatments that employ advanced imaging and complex planning. Modern techniques for delivery of radiotherapy are better at confining radiation dose to the tumor volume while minimizing the irradiation of normal structures. The use of cumbersome blocks, wedges, and tissue compensators has given way to treatment with internal collimation techniques such as IMRT, SBRT, and SRS. These techniques rely heavily on image guidance for tumor targeting. Four-dimensional planning and treatment allow radiation oncologists to track tumor and normal tissue motion, thereby increasing the accuracy and precision of radiation treatments.
As is true in the community, IMRT and IGRT are widely available within the VHA. According to a survey by Simpson and colleagues evaluating the use of IGRT in the U.S., 93% of radiation oncologists use IGRT.7 Similarly, the survey presented here demonstrates that 91% of VHA radiation oncologists report availability of IGRT at their centers. All VHA radiation oncologists surveyed report access to IMRT.
Shen’s recent report evaluating radiotherapy patterns of practice from 2002 to 2010 examined volume of payments for treatment delivery by codes for office-based IMRT.8 These authors noted an increase in the usage of IMRT as a percentage of external beam radiotherapy from 2002 to 2010 of 0% to 70%, respectively. They further noted during this period that IGRT use, based on total payments for treatment delivery, increased from 2.1% to 11.1%.
The reported use of onsite SBRT among VHA physicians is slightly less than that of community physicians. A survey study by Pan and colleagues demonstrated that 63.9% of U.S. radiation oncologists use SBRT, while in the survey study presented here, 53% of VHA radiation oncologists reported availability of onsite SBRT.9 Of note, the lack of availability of onsite SBRT at VHA centers does not preclude treatment with SBRT when medically necessary. These cases can be referred to other VHA or community centers with the requisite accreditation credentials. Because of the increasing use of SBRT and related technologies in the treatment of some cancers, an improved availability of SBRT in the future within the VHA will allow for some centers to participate in the Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which was approved for open recruitment in 2015.
Although BT and SRS are not as widely available within the VHA as other evaluated technologies such as IGRT and IMRT, their availability mirrors a similar limited availability in the community.10-12 When necessary these services also can be provided for veterans through referral to other VHA or non-VHA centers.
The benefit of charged particle radiotherapy, such as proton beam radiotherapy, is limited to specific cancers.13 This technology is not widely available in the community or within the VHA. Because of a VHA policy currently in place permitting non-VHA care when needed, veterans who require treatment with charged particle radiotherapy are referred to accredited non-VHA radiation oncology centers when indicated.
Conclusion
In this survey, 92% of the VHA radiation oncology centers are accredited by the American College of Radiology. Further, VHA radiation oncologists respondents reported availability of treatment technologies in line with responses of physicians from community based surveys. The majority of VHA radiation oncologists report access to IMRT, IGRT, CBCT, and SBRT. While BT and SRS are not available onsite at the majority of the 40 VHA radiation oncology centers, this mirrors limited availability and use of these technologies in the community as well.
Acknowledgments
This article was based on a presentation at the ASCO Quality Care Symposium (October 17-18, 2014) in Boston, Massachusetts. Dawson GA, Cheuk AV, Jolly S, et al. Advanced radiation oncology technology within the Veterans Health Administration (VHA). J Clin Oncol. 214;32(suppl 30):52.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Click here to read the digital edition.
1. National Center for Veterans Analysis and Statistics. 2010 National Survey of Veterans: reported plan to use VA health care in the future. U.S. Department of Veteran Affairs website. http://www.va.gov/vetdata/docs/QuickFacts/2010NSV_Quick_Fact_Final.pdf. Published December 2011. Accessed April 4, 2016.
2. National Center for Veterans Analysis and Statistics. 2010 National Survey Veterans: enrollment and usage of VA benefits and services. U.S. Department of Veteran Affairs website. http://www.va.gov/vedata/docs/quickfacts/Surveys-slideshow.pdf. Published August 15, 2011. Accessed April 4, 2016.
3. Zulling LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs health care system. Mil Med. 2012;177(6):693-701.
4. International Atomic Energy Agency. Recent developments in the technology of radiation oncology. International Atomic Energy Agency website. https://www.iaea.org/About/Policy/GC/GC55/GC55InfDocuments/English/gc55inf-5-att1_en.pdf. Accessed April 4, 2016.
5. Dawson GA, Jolly S, Fosmire H, et al; US Veterans Healthcare Administration National Palliative Radiotherapy Task Force. (P114) radiotherapeutic care within the Veterans Health Administration of US veterans with metastatic cancer to the brain: supportive measures (Part 1 of 2 reports). Cancer Network website. http://www.cancernetwork.com/ars-2015/radiotherapeutic-care-within-veterans-health-administration-us-veterans-metastatic-cancer-brain#sthash.fcB6idE7.dpuf. Published April 30, 2015. Accessed April 4, 2016.
6. Cheuk AV, Gutt R, Moghanaki D, et al; US Veterans Healthcare Administration National Palliative Radiotherapy Task Force. (P118) Radiotherapeutic care within the Veterans Health Administration of US veterans with metastatic cancer to the brain: part 2 clinical treatment patterns. Cancer Network website. http://www.cancernetwork.com/ars-2015/radiotherapeutic-care-within-veterans-health-administration-us-veterans-metastatic-cancer-brain-part-2#sthash.fwW0g1RZ.dpuf. Published April 30, 2015. Accessed April 4, 2016.
7. Simpson DR, Lawson JD, Nath SK, Rose BS, Mundt AJ, Mell LK. A survey on the use of image-guided radiotherapy in the United States. Cancer. 2010;116(16):3953–3960.
8. Shen X, Showalter TN, Mishra MV, et al. Radiation oncology services in the modern era: evolving patterns of usage and payments in the office setting for medicare patients from 2000 to 2010. J Oncol Pract. 2014;10(4):e201-e207.
9. Pan H, Simpson DR, Mell LK, Mundt AJ, Lawson JD. A survey of stereotactic body radiotherapy use in the United States. Cancer. 2011;117(19):4566-4572.
10. Mahmood U, Pugh T, Frank S, et al. Declining u se of brachytherapy for the treatment of prostate cancer. Brachytherapy. 2014;13(2):157-162.
11. Halasz LM, Weeks JC, Neville BA, Taback N, Punglia RS. Use of stereotactic radiosurgery for brain metastases from non-small cell lung cancer in the United States. Int J Radiat Oncol Biol Phys. 2013;85(2):e109-e116.
12. Kong FM, Cuneo KC, Wang L, et al. Patterns of practice in radiation therapy for non-small cell lung cancer among members of the American Society for Radiation Oncology. Pract Radiat Oncol. 2014;4(2):e133-e141.
13. Trikalinos TA, Terasawa T, Ip S, Raman G, Lau J. Particle Beam Radiation Therapies for Cancer. Technical Brief, No. 1. Rockville, MD: Agency for Healthcare Research and Quality; 2009.
The VHA is the primary care provider for 20.4% of the more than 21.9 million military veterans.1 Surveys report that over a lifetime, an estimated 28.4% of U.S. veterans will receive some measure of their health care from the VHA.2 An estimated 40,000 new cancer cases are diagnosed each year from these veterans, resulting in a minimum of 175,000 veterans receiving cancer care in VHA facilities.3 The 39 VHA facilities currently with onsite radiation oncology practices annually provide radiation therapy to about 20,000 veterans (Figure 1).
Nationally, tumor control and toxicity outcomes have each improved over recent decades as advances have occurred in imaging, radiation treatment planning, and equipment for the delivery of radiotherapy.4 The VHA has kept pace with these technological advancements to the point where image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy (SBRT) are widely available at VHA centers. Additionally, all active VHA radiation oncology centers have earned accreditation from the American College of Radiology, while 3 new centers are in the process of gaining accreditation.
When technologies deemed to be medically necessary are not available onsite, these treatments are made available to veterans through referral to other VHA or non-VHA centers. Here, the authors present the results of a survey of VHA-based radiation oncologists to evaluate onsite availability of various radiation technologies.
Methods
The VHA Palliative Radiotherapy Task Force constructed an online survey and sent it to the 82 radiation oncologists practicing at the 38 VHA radiation oncology centers that were active at the time. After emailing the survey,follow-up phone calls were made to maximize response rates. The survey was conducted during the months of May and June of 2014.
In this survey, all 82 VHA radiation oncologists were queried on the availability of advanced radiation delivery technologies including IGRT, IMRT, and SBRT at their facilities. The authors also surveyed for presence of brachytherapy (BT) programs, stereotactic radiosurgery (SRS), and cone-beam computed tomography (CBCT). Information was collected regarding the extent to which physicians can treat cases requiring SRS and/or SBRT onsite vs through referral to another facility for treatment. These data were gathered from a survey conducted in conjunction with a larger survey on the practice and patterns of care in the treatment of patients with brain metastases within the VHA.5,6 The data presented here apply to radiation therapy in general and are not limited to the treatment of brain metastases.
Results
The overall response rate was 76% (62 of 82 radiation oncologists). At the time of the survey, 90% (34 of 38) of active VHA radiation oncology treatment facilities were represented. However as of May 2016, there are 40 active VHA radiation oncology centers. Figure 2 describes the availability of various treatment delivery systems. The data demonstrated 100% availability of IMRT. Respondents reported onsite availability of IGRT at 91%, CBCT at 74%, and SBRT at 53%. Treatment technologies that were not as widely available at VHA facilities with inherent radiation oncology practices included SRS at 29% and BT at 21%. For cases requiring SRS, 69% (40 of 58) of respondents who answered this question indicated that they refer patients to other VHA radiation oncology centers or VHA contracted private entities. This report is limited by the following factors:
- A narrow scope of practices was surveyed. The survey was solely sent to VHA physicians at 38 active VHA radiation oncology centers out of 144 VHA hospitals. Therefore the practices at VHA medical centers without active VHA radiation was not acquired with this survey.
- This survey only addresses availability of these newer treatment technologies, not their actual use, in treating cancers predominant within the VHA.
- Literature comparison in this report is based on current use of these technologies for some of the reports cited, rather than availability as this report reflects. As such, direct comparisons could be misleading.
Discussion
Although the total number of veterans has been decreasing in recent years, the number of veterans enrolling into VHA-related programs has been increasing and is expected to expand increase further in years to come.1,2 It is important for radiation oncologists to keep pace with new technologies to ensure their patients have access to the best possible treatments.
Advances in radiation oncology have allowed radiotherapy to evolve from the 2-dimensional treatments of the 1950s to the 1980s, to more targeted treatments that employ advanced imaging and complex planning. Modern techniques for delivery of radiotherapy are better at confining radiation dose to the tumor volume while minimizing the irradiation of normal structures. The use of cumbersome blocks, wedges, and tissue compensators has given way to treatment with internal collimation techniques such as IMRT, SBRT, and SRS. These techniques rely heavily on image guidance for tumor targeting. Four-dimensional planning and treatment allow radiation oncologists to track tumor and normal tissue motion, thereby increasing the accuracy and precision of radiation treatments.
As is true in the community, IMRT and IGRT are widely available within the VHA. According to a survey by Simpson and colleagues evaluating the use of IGRT in the U.S., 93% of radiation oncologists use IGRT.7 Similarly, the survey presented here demonstrates that 91% of VHA radiation oncologists report availability of IGRT at their centers. All VHA radiation oncologists surveyed report access to IMRT.
Shen’s recent report evaluating radiotherapy patterns of practice from 2002 to 2010 examined volume of payments for treatment delivery by codes for office-based IMRT.8 These authors noted an increase in the usage of IMRT as a percentage of external beam radiotherapy from 2002 to 2010 of 0% to 70%, respectively. They further noted during this period that IGRT use, based on total payments for treatment delivery, increased from 2.1% to 11.1%.
The reported use of onsite SBRT among VHA physicians is slightly less than that of community physicians. A survey study by Pan and colleagues demonstrated that 63.9% of U.S. radiation oncologists use SBRT, while in the survey study presented here, 53% of VHA radiation oncologists reported availability of onsite SBRT.9 Of note, the lack of availability of onsite SBRT at VHA centers does not preclude treatment with SBRT when medically necessary. These cases can be referred to other VHA or community centers with the requisite accreditation credentials. Because of the increasing use of SBRT and related technologies in the treatment of some cancers, an improved availability of SBRT in the future within the VHA will allow for some centers to participate in the Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which was approved for open recruitment in 2015.
Although BT and SRS are not as widely available within the VHA as other evaluated technologies such as IGRT and IMRT, their availability mirrors a similar limited availability in the community.10-12 When necessary these services also can be provided for veterans through referral to other VHA or non-VHA centers.
The benefit of charged particle radiotherapy, such as proton beam radiotherapy, is limited to specific cancers.13 This technology is not widely available in the community or within the VHA. Because of a VHA policy currently in place permitting non-VHA care when needed, veterans who require treatment with charged particle radiotherapy are referred to accredited non-VHA radiation oncology centers when indicated.
Conclusion
In this survey, 92% of the VHA radiation oncology centers are accredited by the American College of Radiology. Further, VHA radiation oncologists respondents reported availability of treatment technologies in line with responses of physicians from community based surveys. The majority of VHA radiation oncologists report access to IMRT, IGRT, CBCT, and SBRT. While BT and SRS are not available onsite at the majority of the 40 VHA radiation oncology centers, this mirrors limited availability and use of these technologies in the community as well.
Acknowledgments
This article was based on a presentation at the ASCO Quality Care Symposium (October 17-18, 2014) in Boston, Massachusetts. Dawson GA, Cheuk AV, Jolly S, et al. Advanced radiation oncology technology within the Veterans Health Administration (VHA). J Clin Oncol. 214;32(suppl 30):52.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Click here to read the digital edition.
The VHA is the primary care provider for 20.4% of the more than 21.9 million military veterans.1 Surveys report that over a lifetime, an estimated 28.4% of U.S. veterans will receive some measure of their health care from the VHA.2 An estimated 40,000 new cancer cases are diagnosed each year from these veterans, resulting in a minimum of 175,000 veterans receiving cancer care in VHA facilities.3 The 39 VHA facilities currently with onsite radiation oncology practices annually provide radiation therapy to about 20,000 veterans (Figure 1).
Nationally, tumor control and toxicity outcomes have each improved over recent decades as advances have occurred in imaging, radiation treatment planning, and equipment for the delivery of radiotherapy.4 The VHA has kept pace with these technological advancements to the point where image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy (SBRT) are widely available at VHA centers. Additionally, all active VHA radiation oncology centers have earned accreditation from the American College of Radiology, while 3 new centers are in the process of gaining accreditation.
When technologies deemed to be medically necessary are not available onsite, these treatments are made available to veterans through referral to other VHA or non-VHA centers. Here, the authors present the results of a survey of VHA-based radiation oncologists to evaluate onsite availability of various radiation technologies.
Methods
The VHA Palliative Radiotherapy Task Force constructed an online survey and sent it to the 82 radiation oncologists practicing at the 38 VHA radiation oncology centers that were active at the time. After emailing the survey,follow-up phone calls were made to maximize response rates. The survey was conducted during the months of May and June of 2014.
In this survey, all 82 VHA radiation oncologists were queried on the availability of advanced radiation delivery technologies including IGRT, IMRT, and SBRT at their facilities. The authors also surveyed for presence of brachytherapy (BT) programs, stereotactic radiosurgery (SRS), and cone-beam computed tomography (CBCT). Information was collected regarding the extent to which physicians can treat cases requiring SRS and/or SBRT onsite vs through referral to another facility for treatment. These data were gathered from a survey conducted in conjunction with a larger survey on the practice and patterns of care in the treatment of patients with brain metastases within the VHA.5,6 The data presented here apply to radiation therapy in general and are not limited to the treatment of brain metastases.
Results
The overall response rate was 76% (62 of 82 radiation oncologists). At the time of the survey, 90% (34 of 38) of active VHA radiation oncology treatment facilities were represented. However as of May 2016, there are 40 active VHA radiation oncology centers. Figure 2 describes the availability of various treatment delivery systems. The data demonstrated 100% availability of IMRT. Respondents reported onsite availability of IGRT at 91%, CBCT at 74%, and SBRT at 53%. Treatment technologies that were not as widely available at VHA facilities with inherent radiation oncology practices included SRS at 29% and BT at 21%. For cases requiring SRS, 69% (40 of 58) of respondents who answered this question indicated that they refer patients to other VHA radiation oncology centers or VHA contracted private entities. This report is limited by the following factors:
- A narrow scope of practices was surveyed. The survey was solely sent to VHA physicians at 38 active VHA radiation oncology centers out of 144 VHA hospitals. Therefore the practices at VHA medical centers without active VHA radiation was not acquired with this survey.
- This survey only addresses availability of these newer treatment technologies, not their actual use, in treating cancers predominant within the VHA.
- Literature comparison in this report is based on current use of these technologies for some of the reports cited, rather than availability as this report reflects. As such, direct comparisons could be misleading.
Discussion
Although the total number of veterans has been decreasing in recent years, the number of veterans enrolling into VHA-related programs has been increasing and is expected to expand increase further in years to come.1,2 It is important for radiation oncologists to keep pace with new technologies to ensure their patients have access to the best possible treatments.
Advances in radiation oncology have allowed radiotherapy to evolve from the 2-dimensional treatments of the 1950s to the 1980s, to more targeted treatments that employ advanced imaging and complex planning. Modern techniques for delivery of radiotherapy are better at confining radiation dose to the tumor volume while minimizing the irradiation of normal structures. The use of cumbersome blocks, wedges, and tissue compensators has given way to treatment with internal collimation techniques such as IMRT, SBRT, and SRS. These techniques rely heavily on image guidance for tumor targeting. Four-dimensional planning and treatment allow radiation oncologists to track tumor and normal tissue motion, thereby increasing the accuracy and precision of radiation treatments.
As is true in the community, IMRT and IGRT are widely available within the VHA. According to a survey by Simpson and colleagues evaluating the use of IGRT in the U.S., 93% of radiation oncologists use IGRT.7 Similarly, the survey presented here demonstrates that 91% of VHA radiation oncologists report availability of IGRT at their centers. All VHA radiation oncologists surveyed report access to IMRT.
Shen’s recent report evaluating radiotherapy patterns of practice from 2002 to 2010 examined volume of payments for treatment delivery by codes for office-based IMRT.8 These authors noted an increase in the usage of IMRT as a percentage of external beam radiotherapy from 2002 to 2010 of 0% to 70%, respectively. They further noted during this period that IGRT use, based on total payments for treatment delivery, increased from 2.1% to 11.1%.
The reported use of onsite SBRT among VHA physicians is slightly less than that of community physicians. A survey study by Pan and colleagues demonstrated that 63.9% of U.S. radiation oncologists use SBRT, while in the survey study presented here, 53% of VHA radiation oncologists reported availability of onsite SBRT.9 Of note, the lack of availability of onsite SBRT at VHA centers does not preclude treatment with SBRT when medically necessary. These cases can be referred to other VHA or community centers with the requisite accreditation credentials. Because of the increasing use of SBRT and related technologies in the treatment of some cancers, an improved availability of SBRT in the future within the VHA will allow for some centers to participate in the Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy (VALOR) trial, which was approved for open recruitment in 2015.
Although BT and SRS are not as widely available within the VHA as other evaluated technologies such as IGRT and IMRT, their availability mirrors a similar limited availability in the community.10-12 When necessary these services also can be provided for veterans through referral to other VHA or non-VHA centers.
The benefit of charged particle radiotherapy, such as proton beam radiotherapy, is limited to specific cancers.13 This technology is not widely available in the community or within the VHA. Because of a VHA policy currently in place permitting non-VHA care when needed, veterans who require treatment with charged particle radiotherapy are referred to accredited non-VHA radiation oncology centers when indicated.
Conclusion
In this survey, 92% of the VHA radiation oncology centers are accredited by the American College of Radiology. Further, VHA radiation oncologists respondents reported availability of treatment technologies in line with responses of physicians from community based surveys. The majority of VHA radiation oncologists report access to IMRT, IGRT, CBCT, and SBRT. While BT and SRS are not available onsite at the majority of the 40 VHA radiation oncology centers, this mirrors limited availability and use of these technologies in the community as well.
Acknowledgments
This article was based on a presentation at the ASCO Quality Care Symposium (October 17-18, 2014) in Boston, Massachusetts. Dawson GA, Cheuk AV, Jolly S, et al. Advanced radiation oncology technology within the Veterans Health Administration (VHA). J Clin Oncol. 214;32(suppl 30):52.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Click here to read the digital edition.
1. National Center for Veterans Analysis and Statistics. 2010 National Survey of Veterans: reported plan to use VA health care in the future. U.S. Department of Veteran Affairs website. http://www.va.gov/vetdata/docs/QuickFacts/2010NSV_Quick_Fact_Final.pdf. Published December 2011. Accessed April 4, 2016.
2. National Center for Veterans Analysis and Statistics. 2010 National Survey Veterans: enrollment and usage of VA benefits and services. U.S. Department of Veteran Affairs website. http://www.va.gov/vedata/docs/quickfacts/Surveys-slideshow.pdf. Published August 15, 2011. Accessed April 4, 2016.
3. Zulling LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs health care system. Mil Med. 2012;177(6):693-701.
4. International Atomic Energy Agency. Recent developments in the technology of radiation oncology. International Atomic Energy Agency website. https://www.iaea.org/About/Policy/GC/GC55/GC55InfDocuments/English/gc55inf-5-att1_en.pdf. Accessed April 4, 2016.
5. Dawson GA, Jolly S, Fosmire H, et al; US Veterans Healthcare Administration National Palliative Radiotherapy Task Force. (P114) radiotherapeutic care within the Veterans Health Administration of US veterans with metastatic cancer to the brain: supportive measures (Part 1 of 2 reports). Cancer Network website. http://www.cancernetwork.com/ars-2015/radiotherapeutic-care-within-veterans-health-administration-us-veterans-metastatic-cancer-brain#sthash.fcB6idE7.dpuf. Published April 30, 2015. Accessed April 4, 2016.
6. Cheuk AV, Gutt R, Moghanaki D, et al; US Veterans Healthcare Administration National Palliative Radiotherapy Task Force. (P118) Radiotherapeutic care within the Veterans Health Administration of US veterans with metastatic cancer to the brain: part 2 clinical treatment patterns. Cancer Network website. http://www.cancernetwork.com/ars-2015/radiotherapeutic-care-within-veterans-health-administration-us-veterans-metastatic-cancer-brain-part-2#sthash.fwW0g1RZ.dpuf. Published April 30, 2015. Accessed April 4, 2016.
7. Simpson DR, Lawson JD, Nath SK, Rose BS, Mundt AJ, Mell LK. A survey on the use of image-guided radiotherapy in the United States. Cancer. 2010;116(16):3953–3960.
8. Shen X, Showalter TN, Mishra MV, et al. Radiation oncology services in the modern era: evolving patterns of usage and payments in the office setting for medicare patients from 2000 to 2010. J Oncol Pract. 2014;10(4):e201-e207.
9. Pan H, Simpson DR, Mell LK, Mundt AJ, Lawson JD. A survey of stereotactic body radiotherapy use in the United States. Cancer. 2011;117(19):4566-4572.
10. Mahmood U, Pugh T, Frank S, et al. Declining u se of brachytherapy for the treatment of prostate cancer. Brachytherapy. 2014;13(2):157-162.
11. Halasz LM, Weeks JC, Neville BA, Taback N, Punglia RS. Use of stereotactic radiosurgery for brain metastases from non-small cell lung cancer in the United States. Int J Radiat Oncol Biol Phys. 2013;85(2):e109-e116.
12. Kong FM, Cuneo KC, Wang L, et al. Patterns of practice in radiation therapy for non-small cell lung cancer among members of the American Society for Radiation Oncology. Pract Radiat Oncol. 2014;4(2):e133-e141.
13. Trikalinos TA, Terasawa T, Ip S, Raman G, Lau J. Particle Beam Radiation Therapies for Cancer. Technical Brief, No. 1. Rockville, MD: Agency for Healthcare Research and Quality; 2009.
1. National Center for Veterans Analysis and Statistics. 2010 National Survey of Veterans: reported plan to use VA health care in the future. U.S. Department of Veteran Affairs website. http://www.va.gov/vetdata/docs/QuickFacts/2010NSV_Quick_Fact_Final.pdf. Published December 2011. Accessed April 4, 2016.
2. National Center for Veterans Analysis and Statistics. 2010 National Survey Veterans: enrollment and usage of VA benefits and services. U.S. Department of Veteran Affairs website. http://www.va.gov/vedata/docs/quickfacts/Surveys-slideshow.pdf. Published August 15, 2011. Accessed April 4, 2016.
3. Zulling LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs health care system. Mil Med. 2012;177(6):693-701.
4. International Atomic Energy Agency. Recent developments in the technology of radiation oncology. International Atomic Energy Agency website. https://www.iaea.org/About/Policy/GC/GC55/GC55InfDocuments/English/gc55inf-5-att1_en.pdf. Accessed April 4, 2016.
5. Dawson GA, Jolly S, Fosmire H, et al; US Veterans Healthcare Administration National Palliative Radiotherapy Task Force. (P114) radiotherapeutic care within the Veterans Health Administration of US veterans with metastatic cancer to the brain: supportive measures (Part 1 of 2 reports). Cancer Network website. http://www.cancernetwork.com/ars-2015/radiotherapeutic-care-within-veterans-health-administration-us-veterans-metastatic-cancer-brain#sthash.fcB6idE7.dpuf. Published April 30, 2015. Accessed April 4, 2016.
6. Cheuk AV, Gutt R, Moghanaki D, et al; US Veterans Healthcare Administration National Palliative Radiotherapy Task Force. (P118) Radiotherapeutic care within the Veterans Health Administration of US veterans with metastatic cancer to the brain: part 2 clinical treatment patterns. Cancer Network website. http://www.cancernetwork.com/ars-2015/radiotherapeutic-care-within-veterans-health-administration-us-veterans-metastatic-cancer-brain-part-2#sthash.fwW0g1RZ.dpuf. Published April 30, 2015. Accessed April 4, 2016.
7. Simpson DR, Lawson JD, Nath SK, Rose BS, Mundt AJ, Mell LK. A survey on the use of image-guided radiotherapy in the United States. Cancer. 2010;116(16):3953–3960.
8. Shen X, Showalter TN, Mishra MV, et al. Radiation oncology services in the modern era: evolving patterns of usage and payments in the office setting for medicare patients from 2000 to 2010. J Oncol Pract. 2014;10(4):e201-e207.
9. Pan H, Simpson DR, Mell LK, Mundt AJ, Lawson JD. A survey of stereotactic body radiotherapy use in the United States. Cancer. 2011;117(19):4566-4572.
10. Mahmood U, Pugh T, Frank S, et al. Declining u se of brachytherapy for the treatment of prostate cancer. Brachytherapy. 2014;13(2):157-162.
11. Halasz LM, Weeks JC, Neville BA, Taback N, Punglia RS. Use of stereotactic radiosurgery for brain metastases from non-small cell lung cancer in the United States. Int J Radiat Oncol Biol Phys. 2013;85(2):e109-e116.
12. Kong FM, Cuneo KC, Wang L, et al. Patterns of practice in radiation therapy for non-small cell lung cancer among members of the American Society for Radiation Oncology. Pract Radiat Oncol. 2014;4(2):e133-e141.
13. Trikalinos TA, Terasawa T, Ip S, Raman G, Lau J. Particle Beam Radiation Therapies for Cancer. Technical Brief, No. 1. Rockville, MD: Agency for Healthcare Research and Quality; 2009.
Consensus Statement Supporting the Recommendation for Single-Fraction Palliative Radiotherapy for Uncomplicated, Painful Bone Metastases
The authors would like to acknowledge Tony Quang, MD, JD, for the advice given on this project.
Palliative radiotherapy for bone metastases is typically delivered either as a short course of 1 to 5 fractions or protracted over longer courses of up to 20 treatments. These longer courses can be burdensome and discourage its utilization, despite a 50% to 80% likelihood of meaningful pain relief from only a single fraction of radiation therapy. Meanwhile, there are multiple randomized studies that have demonstrated that shorter course(s) are equivalent for pain control.
Although the VHA currently has 143 medical facilities that have cancer diagnostic and treatment capabilities, only 40 have radiation oncology services on-site.1 Thus, access to palliative radiotherapy may be limited for veterans who do not live close by, and many may seek care outside the VHA. At VHA radiation oncology centers, single-fraction radiation therapy (SFRT) is routinely offered by the majority of radiation oncologists.2,3 However, the longer course is commonly preferred outside the VA, and a recent SEER-Medicare analysis of more than 3,000 patients demonstrated that the majority of patients treated outside the VA actually receive more than 10 treatments.4 For this reason, the VA National Palliative Radiotherapy Task Force prepared this document to provide guidance for clinicians within and outside the VA to increase awareness of the appropriateness, effectiveness, and convenience of SFRT as opposed to longer courses of treatment that increase the burden of care at the end of life and often are unnecessary.
Veterans, Cancer, and Metastases
Within the VA, an estimated 40,000 new cancer cases are diagnosed each year, and 175,000 veterans undergo cancer care within the VHA annually.1 Unfortunately, the majority will develop bone metastases with postmortem examinations, suggesting that the rate can be as high as 90% at the end of life.5-7 For many, including veterans with cancer, pain control can be difficult, and access to palliative radiotherapy is critical.8
Single-Fraction Palliatiev Radiation Therapy
Historically, patients with painful bone metastases have been treated with courses of palliative radiotherapy ranging between 2 and 4 weeks of daily treatments. However, several large randomized clinical trials comparing a single treatment with multiple treatments have established that SFRT provides equivalent rates of pain relief even when it may be required for a second time.9-12 Recommendations based on these trials have been incorporated into various treatment guidelines that widely acknowledge the efficacy of SFRT.13-15
For this reason, SFRT is often preferred at many centers because it is substantially more convenient for patients with cancer. It reduces travel time for daily radiation clinic visits, which allows for more time with loved ones outside the medical establishment. Furthermore, SFRT improves patient access to radiotherapy and reduces costs. The benefits can be direct as well as indirect to those who have to take time for numerous visits.
Longer courses of palliative radiotherapy can be burdensome for patients and primary care providers. Unnecessarily protracted courses of palliative radiotherapy also delay the receipt of systemic therapies because they are typically considered unsafe to administer concurrently. Moreover, when SFRT is unavailable, the burden of long-course palliation is known to discourage health care providers from referring patients since opioid therapy is more convenient, even though it exchanges lucidity for analgesia.16,17
For this reason, the authors believe that it is in the best interest for veterans with terminal cancers and their providers to be aware of the shorter SFRT for effective, convenient pain relief. This treatment option is particularly relevant for patients with a poor performance status, patients already in hospice care, or patient who travel long distances.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Click here to read the digital edition.
1. Zullig LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs Health Care System. Mil Med. 2012;177(6):693-701.
2. Moghanaki D, Cheuk AV, Fosmire H, et al; U.S. Veterans Healthcare Administration National Palliative Radiotherapy Taskforce. Availability of single fraction palliative radiotherapy for cancer patients receiving end-of-life care within the Veterans Healthcare Administration. J Palliat Med. 2014;17(11):1221-1225.
3. Dawson GA, Glushko I, Hagan MP. A cross-sectional view of radiation dose fractionation schemes used for painful bone metastases cases within Veterans Health Administration Radiation Oncology Centers. J Clin Oncol. 2015;33(29 suppl):abstract 177.
4. Bekelman JE, Epstein AJ, Emanuel EJ. Single- vs multiple-fraction radiotherapy for bone metastases from prostate cancer. JAMA. 2013;310(14):1501-1502.
5. Galasko CSB. The anatomy and pathways of skeletal metastases. In: Weiss L, Gilbert AH, eds. Bone Metastasis. Boston, MA: GK Hall; 1981:49-63.
6. Bubendorf L, Schöpfer A, Wagner U, et al. Metastatic patterns in prostate cancer: an autopsy study of 1,589 patients. Hum Pathol. 2000;31(5):578-583.
7. Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12(20, pt 2):6243s-6249s.
8. Geriatrics and Extended Care Strategic Healthcare Group, National Pain Management Coordinating Committee, Veterans Health Administration. Pain as the 5th Vital Sign Toolkit. Rev. ed. Washington, DC: National Pain Management Coordinating Committee; 2000.
9. Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97(11):798-804.
10. Chow E, Hoskins PJ, Wu J, et al. A phase III international randomised trial comparing single with multiple fractions for re-irradiation of painful bone metastases: National Cancer Institute of Canada Clinical Trials Group (NCTC CTG) SC 20. Clin Oncol (R Coll Radiol). 2006;18(2):125-128.
11. Fairchild A, Barnes E, Ghosh S, et al. International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice? Int J Radiat Oncol Biol Phys. 2009;75(5):1501-1510.
12. Chow E, van der Linden YM, Roos D, et al. Single fraction versus multiple fractions of repeat radiation for painful bone metastases: a randomised, controlled, non-inferiority trial. Lancet Oncol. 2014;15(2):164-171.
13. Lutz ST, Berk L, Chang E, et al; American Society for Radiation Oncology (ASTRO). Palliative radiotherapy for bone metastases: an ASTRO evidencebased guideline. Int J Radiat Oncol, Biol, Phys. 2011;79(4):965-976.
14. Expert Panel on Radiation Oncology-Bone Metastases, Lo SS, Lutz ST, Chang EL, et al. ACR Appropriateness Criteria® spinal bone metastases. J Palliat Med. 2013;16(1):9-19.
15. Expert Panel on Radiation Oncology-Bone Metastases, Lutz ST, Lo SS, Chang EL, et al. ACR Appropriateness Criteria® non-spinal bone metastases. J Palliative Med. 2012;15(5):521-526.
16. Guadagnolo BA, Liao KP, Elting L, Giordano S, Buchholz TA, Shih YC. Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States. J Clin Oncol. 2013;31(1):80-87.
17. Schuster J, Han T, Anscher M, Moghanaki D. Hospice providers awareness of the benefits and availability of single-fraction palliative radiotherapy. J Hospice Palliat Care Nurs. 2014;16(2):67-72.
18. Cheon PM, Wong E, Thavarajah N, et al. A definition of “uncomplicated bone metastases” based on previous bone metastases trials comparing single-fraction and multi-fraction radiation therapy. J Bone Oncol. 2015;4(1):13-17.
The authors would like to acknowledge Tony Quang, MD, JD, for the advice given on this project.
Palliative radiotherapy for bone metastases is typically delivered either as a short course of 1 to 5 fractions or protracted over longer courses of up to 20 treatments. These longer courses can be burdensome and discourage its utilization, despite a 50% to 80% likelihood of meaningful pain relief from only a single fraction of radiation therapy. Meanwhile, there are multiple randomized studies that have demonstrated that shorter course(s) are equivalent for pain control.
Although the VHA currently has 143 medical facilities that have cancer diagnostic and treatment capabilities, only 40 have radiation oncology services on-site.1 Thus, access to palliative radiotherapy may be limited for veterans who do not live close by, and many may seek care outside the VHA. At VHA radiation oncology centers, single-fraction radiation therapy (SFRT) is routinely offered by the majority of radiation oncologists.2,3 However, the longer course is commonly preferred outside the VA, and a recent SEER-Medicare analysis of more than 3,000 patients demonstrated that the majority of patients treated outside the VA actually receive more than 10 treatments.4 For this reason, the VA National Palliative Radiotherapy Task Force prepared this document to provide guidance for clinicians within and outside the VA to increase awareness of the appropriateness, effectiveness, and convenience of SFRT as opposed to longer courses of treatment that increase the burden of care at the end of life and often are unnecessary.
Veterans, Cancer, and Metastases
Within the VA, an estimated 40,000 new cancer cases are diagnosed each year, and 175,000 veterans undergo cancer care within the VHA annually.1 Unfortunately, the majority will develop bone metastases with postmortem examinations, suggesting that the rate can be as high as 90% at the end of life.5-7 For many, including veterans with cancer, pain control can be difficult, and access to palliative radiotherapy is critical.8
Single-Fraction Palliatiev Radiation Therapy
Historically, patients with painful bone metastases have been treated with courses of palliative radiotherapy ranging between 2 and 4 weeks of daily treatments. However, several large randomized clinical trials comparing a single treatment with multiple treatments have established that SFRT provides equivalent rates of pain relief even when it may be required for a second time.9-12 Recommendations based on these trials have been incorporated into various treatment guidelines that widely acknowledge the efficacy of SFRT.13-15
For this reason, SFRT is often preferred at many centers because it is substantially more convenient for patients with cancer. It reduces travel time for daily radiation clinic visits, which allows for more time with loved ones outside the medical establishment. Furthermore, SFRT improves patient access to radiotherapy and reduces costs. The benefits can be direct as well as indirect to those who have to take time for numerous visits.
Longer courses of palliative radiotherapy can be burdensome for patients and primary care providers. Unnecessarily protracted courses of palliative radiotherapy also delay the receipt of systemic therapies because they are typically considered unsafe to administer concurrently. Moreover, when SFRT is unavailable, the burden of long-course palliation is known to discourage health care providers from referring patients since opioid therapy is more convenient, even though it exchanges lucidity for analgesia.16,17
For this reason, the authors believe that it is in the best interest for veterans with terminal cancers and their providers to be aware of the shorter SFRT for effective, convenient pain relief. This treatment option is particularly relevant for patients with a poor performance status, patients already in hospice care, or patient who travel long distances.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Click here to read the digital edition.
The authors would like to acknowledge Tony Quang, MD, JD, for the advice given on this project.
Palliative radiotherapy for bone metastases is typically delivered either as a short course of 1 to 5 fractions or protracted over longer courses of up to 20 treatments. These longer courses can be burdensome and discourage its utilization, despite a 50% to 80% likelihood of meaningful pain relief from only a single fraction of radiation therapy. Meanwhile, there are multiple randomized studies that have demonstrated that shorter course(s) are equivalent for pain control.
Although the VHA currently has 143 medical facilities that have cancer diagnostic and treatment capabilities, only 40 have radiation oncology services on-site.1 Thus, access to palliative radiotherapy may be limited for veterans who do not live close by, and many may seek care outside the VHA. At VHA radiation oncology centers, single-fraction radiation therapy (SFRT) is routinely offered by the majority of radiation oncologists.2,3 However, the longer course is commonly preferred outside the VA, and a recent SEER-Medicare analysis of more than 3,000 patients demonstrated that the majority of patients treated outside the VA actually receive more than 10 treatments.4 For this reason, the VA National Palliative Radiotherapy Task Force prepared this document to provide guidance for clinicians within and outside the VA to increase awareness of the appropriateness, effectiveness, and convenience of SFRT as opposed to longer courses of treatment that increase the burden of care at the end of life and often are unnecessary.
Veterans, Cancer, and Metastases
Within the VA, an estimated 40,000 new cancer cases are diagnosed each year, and 175,000 veterans undergo cancer care within the VHA annually.1 Unfortunately, the majority will develop bone metastases with postmortem examinations, suggesting that the rate can be as high as 90% at the end of life.5-7 For many, including veterans with cancer, pain control can be difficult, and access to palliative radiotherapy is critical.8
Single-Fraction Palliatiev Radiation Therapy
Historically, patients with painful bone metastases have been treated with courses of palliative radiotherapy ranging between 2 and 4 weeks of daily treatments. However, several large randomized clinical trials comparing a single treatment with multiple treatments have established that SFRT provides equivalent rates of pain relief even when it may be required for a second time.9-12 Recommendations based on these trials have been incorporated into various treatment guidelines that widely acknowledge the efficacy of SFRT.13-15
For this reason, SFRT is often preferred at many centers because it is substantially more convenient for patients with cancer. It reduces travel time for daily radiation clinic visits, which allows for more time with loved ones outside the medical establishment. Furthermore, SFRT improves patient access to radiotherapy and reduces costs. The benefits can be direct as well as indirect to those who have to take time for numerous visits.
Longer courses of palliative radiotherapy can be burdensome for patients and primary care providers. Unnecessarily protracted courses of palliative radiotherapy also delay the receipt of systemic therapies because they are typically considered unsafe to administer concurrently. Moreover, when SFRT is unavailable, the burden of long-course palliation is known to discourage health care providers from referring patients since opioid therapy is more convenient, even though it exchanges lucidity for analgesia.16,17
For this reason, the authors believe that it is in the best interest for veterans with terminal cancers and their providers to be aware of the shorter SFRT for effective, convenient pain relief. This treatment option is particularly relevant for patients with a poor performance status, patients already in hospice care, or patient who travel long distances.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Click here to read the digital edition.
1. Zullig LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs Health Care System. Mil Med. 2012;177(6):693-701.
2. Moghanaki D, Cheuk AV, Fosmire H, et al; U.S. Veterans Healthcare Administration National Palliative Radiotherapy Taskforce. Availability of single fraction palliative radiotherapy for cancer patients receiving end-of-life care within the Veterans Healthcare Administration. J Palliat Med. 2014;17(11):1221-1225.
3. Dawson GA, Glushko I, Hagan MP. A cross-sectional view of radiation dose fractionation schemes used for painful bone metastases cases within Veterans Health Administration Radiation Oncology Centers. J Clin Oncol. 2015;33(29 suppl):abstract 177.
4. Bekelman JE, Epstein AJ, Emanuel EJ. Single- vs multiple-fraction radiotherapy for bone metastases from prostate cancer. JAMA. 2013;310(14):1501-1502.
5. Galasko CSB. The anatomy and pathways of skeletal metastases. In: Weiss L, Gilbert AH, eds. Bone Metastasis. Boston, MA: GK Hall; 1981:49-63.
6. Bubendorf L, Schöpfer A, Wagner U, et al. Metastatic patterns in prostate cancer: an autopsy study of 1,589 patients. Hum Pathol. 2000;31(5):578-583.
7. Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12(20, pt 2):6243s-6249s.
8. Geriatrics and Extended Care Strategic Healthcare Group, National Pain Management Coordinating Committee, Veterans Health Administration. Pain as the 5th Vital Sign Toolkit. Rev. ed. Washington, DC: National Pain Management Coordinating Committee; 2000.
9. Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97(11):798-804.
10. Chow E, Hoskins PJ, Wu J, et al. A phase III international randomised trial comparing single with multiple fractions for re-irradiation of painful bone metastases: National Cancer Institute of Canada Clinical Trials Group (NCTC CTG) SC 20. Clin Oncol (R Coll Radiol). 2006;18(2):125-128.
11. Fairchild A, Barnes E, Ghosh S, et al. International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice? Int J Radiat Oncol Biol Phys. 2009;75(5):1501-1510.
12. Chow E, van der Linden YM, Roos D, et al. Single fraction versus multiple fractions of repeat radiation for painful bone metastases: a randomised, controlled, non-inferiority trial. Lancet Oncol. 2014;15(2):164-171.
13. Lutz ST, Berk L, Chang E, et al; American Society for Radiation Oncology (ASTRO). Palliative radiotherapy for bone metastases: an ASTRO evidencebased guideline. Int J Radiat Oncol, Biol, Phys. 2011;79(4):965-976.
14. Expert Panel on Radiation Oncology-Bone Metastases, Lo SS, Lutz ST, Chang EL, et al. ACR Appropriateness Criteria® spinal bone metastases. J Palliat Med. 2013;16(1):9-19.
15. Expert Panel on Radiation Oncology-Bone Metastases, Lutz ST, Lo SS, Chang EL, et al. ACR Appropriateness Criteria® non-spinal bone metastases. J Palliative Med. 2012;15(5):521-526.
16. Guadagnolo BA, Liao KP, Elting L, Giordano S, Buchholz TA, Shih YC. Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States. J Clin Oncol. 2013;31(1):80-87.
17. Schuster J, Han T, Anscher M, Moghanaki D. Hospice providers awareness of the benefits and availability of single-fraction palliative radiotherapy. J Hospice Palliat Care Nurs. 2014;16(2):67-72.
18. Cheon PM, Wong E, Thavarajah N, et al. A definition of “uncomplicated bone metastases” based on previous bone metastases trials comparing single-fraction and multi-fraction radiation therapy. J Bone Oncol. 2015;4(1):13-17.
1. Zullig LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs Health Care System. Mil Med. 2012;177(6):693-701.
2. Moghanaki D, Cheuk AV, Fosmire H, et al; U.S. Veterans Healthcare Administration National Palliative Radiotherapy Taskforce. Availability of single fraction palliative radiotherapy for cancer patients receiving end-of-life care within the Veterans Healthcare Administration. J Palliat Med. 2014;17(11):1221-1225.
3. Dawson GA, Glushko I, Hagan MP. A cross-sectional view of radiation dose fractionation schemes used for painful bone metastases cases within Veterans Health Administration Radiation Oncology Centers. J Clin Oncol. 2015;33(29 suppl):abstract 177.
4. Bekelman JE, Epstein AJ, Emanuel EJ. Single- vs multiple-fraction radiotherapy for bone metastases from prostate cancer. JAMA. 2013;310(14):1501-1502.
5. Galasko CSB. The anatomy and pathways of skeletal metastases. In: Weiss L, Gilbert AH, eds. Bone Metastasis. Boston, MA: GK Hall; 1981:49-63.
6. Bubendorf L, Schöpfer A, Wagner U, et al. Metastatic patterns in prostate cancer: an autopsy study of 1,589 patients. Hum Pathol. 2000;31(5):578-583.
7. Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12(20, pt 2):6243s-6249s.
8. Geriatrics and Extended Care Strategic Healthcare Group, National Pain Management Coordinating Committee, Veterans Health Administration. Pain as the 5th Vital Sign Toolkit. Rev. ed. Washington, DC: National Pain Management Coordinating Committee; 2000.
9. Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97(11):798-804.
10. Chow E, Hoskins PJ, Wu J, et al. A phase III international randomised trial comparing single with multiple fractions for re-irradiation of painful bone metastases: National Cancer Institute of Canada Clinical Trials Group (NCTC CTG) SC 20. Clin Oncol (R Coll Radiol). 2006;18(2):125-128.
11. Fairchild A, Barnes E, Ghosh S, et al. International patterns of practice in palliative radiotherapy for painful bone metastases: evidence-based practice? Int J Radiat Oncol Biol Phys. 2009;75(5):1501-1510.
12. Chow E, van der Linden YM, Roos D, et al. Single fraction versus multiple fractions of repeat radiation for painful bone metastases: a randomised, controlled, non-inferiority trial. Lancet Oncol. 2014;15(2):164-171.
13. Lutz ST, Berk L, Chang E, et al; American Society for Radiation Oncology (ASTRO). Palliative radiotherapy for bone metastases: an ASTRO evidencebased guideline. Int J Radiat Oncol, Biol, Phys. 2011;79(4):965-976.
14. Expert Panel on Radiation Oncology-Bone Metastases, Lo SS, Lutz ST, Chang EL, et al. ACR Appropriateness Criteria® spinal bone metastases. J Palliat Med. 2013;16(1):9-19.
15. Expert Panel on Radiation Oncology-Bone Metastases, Lutz ST, Lo SS, Chang EL, et al. ACR Appropriateness Criteria® non-spinal bone metastases. J Palliative Med. 2012;15(5):521-526.
16. Guadagnolo BA, Liao KP, Elting L, Giordano S, Buchholz TA, Shih YC. Use of radiation therapy in the last 30 days of life among a large population-based cohort of elderly patients in the United States. J Clin Oncol. 2013;31(1):80-87.
17. Schuster J, Han T, Anscher M, Moghanaki D. Hospice providers awareness of the benefits and availability of single-fraction palliative radiotherapy. J Hospice Palliat Care Nurs. 2014;16(2):67-72.
18. Cheon PM, Wong E, Thavarajah N, et al. A definition of “uncomplicated bone metastases” based on previous bone metastases trials comparing single-fraction and multi-fraction radiation therapy. J Bone Oncol. 2015;4(1):13-17.