EXECUTIVE SUMMARY

Residents, practicing radiation oncologists, and program directors believe palliative care training is important, but education is lacking in some areas, according to multiple recent studies. Some possible solutions include the following:

• Make the palliative care team available to support radiation oncologists.

• Ensure radiation oncology trainees spend clinical time with palliative care providers.

• Develop national standards for palliative care training in radiation oncology.


Although 96% of radiation oncology residents see palliative care as an important competency, most feel their training is inadequate, found a recent study.1

“Palliative care is an important part of an oncologist’s practice and, specifically, a radiation oncologist’s practice, where 30% to 40% of the patients are seen for a palliative radiation consult,” says Monica S. Krishnan, MD, the study’s lead author. Krishnan is an assistant professor of radiation oncology at Harvard Medical School in Boston.

Researchers surveyed 404 radiation oncology residents. Most (81%) wanted more palliative care education. “We were surprised to note that, on average, 79% of residents rated their training in palliative care as ‘not/minimally/somewhat’ adequate across all palliative care domains,” says Krishnan. These include symptom management; communication on goals of care; advance care planning; care coordination; and psychosocial, cultural, spiritual, legal, and ethical issues. “These findings highlighted the need to improve palliative care education during training,” concludes Krishnan.

Need Support From Colleagues

With so much clinical content to learn in the highly technical field of radiation oncology, “the curriculum becomes very full,” says F. Amos Bailey, MD, FACP, FAAHPM, professor of palliative medicine at University of Colorado Anschutz Medical Campus in Aurora.

Radiation oncologists need support from colleagues with expertise in palliative care, says Bailey. “Providers can learn these skills. They are not just innate.” He recommends making the following changes:

• making members of the palliative care team available to support radiation oncologists;

• having radiation oncology trainees spend clinical time with palliative care providers to better understand the experiences of the patients and families they are caring for in the last months and weeks of life;

• ensuring appropriate use of single or limited fraction treatment plans for patients needing palliative radiation;

• developing standards and requirements for palliative care in radiation oncology training and in postgraduate training.

Little Structured Training

A growing body of research points to radiation oncologists’ need for palliative care training. A recent study assessed 162 consults for palliative radiation therapy in 2014 at three Boston-area hospitals. Researchers found that clinicians encountered multiple palliative care issues, including physical symptoms and goals of care.2

Ninety-one percent of radiation oncologists believe palliative and supportive care is an important competency for their specialty, found a recent survey of 4,093 radiation oncologists.3 While most are moderately confident in their ability to assess and manage pain and gastrointestinal symptoms, the same isn’t true for their ability to manage anorexia, anxiety, and depression. Despite these areas of decreased confidence, 42% do not receive any additional palliative and supportive care education beyond their residency training.

Another study surveyed 87 program directors of radiation oncology residency programs. While 93% agreed or strongly agreed that palliative and supportive care are important competencies for radiation oncology residents and fellows, only 67% of residency programs had formal educational activities in principles and practice of palliative supportive care.4

The researchers, a group of radiation oncologists, suspected their specialty was not providing enough structured education to provide good palliative care. “And sure enough, even though the programs did provide quite good radiation oncology-specific palliative education, the survey showed they provided little structured training in the broader field of palliative care,” says Gabrielle Kane, MD, another of the study’s authors. Kane is medical director of radiation oncology at Seattle-based UW Medical Center. However, program directors did have an interest in expanding and improving palliative care education.

Kavita Dharmarajan, MD, another of the study’s authors, concurs. “The findings confirmed our hypothesis — that most directors believed palliative care was an important competency for trainees to develop, but that there were certain ‘holes’ in the training,” says Dharmarajan, assistant professor of radiation oncology and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City.

Before the study, little was known about whether and how radiation oncology training programs incorporated palliative care training. “Now that we know the areas where teaching is insufficient, we can focus on creating education tools to address those particular concepts,” says Dharmarajan.

The researchers hope that a national curriculum and clear guidelines will be developed. “We have now raised awareness,” says Kane. “There is a motivated and active group within the specialty who are focused on helping improve this educational need.”

Decision-making Is Complex

The need for good communication on advance care planning is a key issue uncovered in the studies. This includes considering not offering radiation to patients who are unlikely to see a timely benefit from the treatment.

“It is unethical for us to give a treatment that, in all likelihood, would be futile,” says Dharmarajan. Radiation oncologists should not routinely give 10 fraction treatments to patients whose prognosis is limited to weeks, for instance. “And if it’s limited to days — or if treatment is likely to be more burdensome than helpful — we probably shouldn’t be giving any radiation at all,” says Dharmarajan.

Kane says palliative radiotherapy is a “large and important component” of radiation oncology. “Trainees learn a lot about this aspect of palliation, but very little about the more holistic approach of palliative care — controlling all symptoms with multiple modalities — and the sometimes terrifying emotional aspects of end-of-life issues,” she says.

Though the technical aspects of palliative radiation are straightforward, decision-making often is more complex. “Radiation oncologists are somewhat more isolated in their practice, living down in the basement with their big machines instead of in the hub of inpatient units,” explains Kane. Other specialists’ ways of palliating cancer patients’ symptoms also come into play. For instance, side effects of certain medications can hinder the ability to deliver palliative radiation therapy.

Patients are typically referred back to their primary oncologist to address issues such as side effects of radiation. This is especially likely if patients are no longer under the direct care of the radiation oncologist. However, says Dharmarajan, “Ethically, we as radiation oncologists have a responsibility to see patients through the course of radiation treatment and the immediate period after it.”

REFERENCES

1. Krishnan M, Racsa M, Jones J, et al. Radiation oncology resident palliative education. Pract Radiat Oncol 2017 Mar 14. pii: S1879-8500(17)30068-1. doi: 10.1016/j.prro.2017.03.007. [Epub ahead of print]

2. Parker GM, LeBaron VT, Krishnan M, et al. Burden of palliative care issues encountered by radiation oncologists caring for patients with advanced cancer. Pract Radiat Oncol 2017 May 25. pii: S1879-8500(17)30171-6. doi: 10.1016/j.prro.2017.05.005. [Epub ahead of print]

3. Wei RL, Mattes MD, Yu J, et al. Attitudes of radiation oncologists toward palliative and supportive care in the United States: Report on national membership survey by the American Society for Radiation Oncology (ASTRO). Pract Radiat Oncol 2017; 7(2):113-119.

4. Wei RL, Colbert LE, Jones J, et al. Palliative care and palliative radiation therapy education in radiation oncology: A survey of US radiation oncology program directors. Pract Radiat Oncol 2017; 7(4):234-240.

SOURCES

• F. Amos Bailey, MD, FACP, FAAHPM, Professor of Palliative Medicine, University of Colorado Anschutz Medical Campus, Aurora. Phone: (303) 724-9674. Fax: (303) 724-2270. Email: amos.bailey@ucdenver.edu.

• Kavita Dharmarajan, MD, Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York City. Email: kavita.dharmarajan@mountsinai.org.

• Gabrielle Kane, MD, Medical Director of Radiation Oncology, UW Medical Center, Seattle. Phone: (206) 598 4121. Email: kaneg@uw.edu.