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Physician And Patient Barriers To Radiotherapy Service Access: Treatment Referral Implications

Authors Chierchini S, Ingrosso G , Saldi S, Stracci F, Aristei C

Received 18 June 2019

Accepted for publication 14 September 2019

Published 7 October 2019 Volume 2019:11 Pages 8829—8833

DOI https://doi.org/10.2147/CMAR.S168941

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 3

Editor who approved publication: Dr A. Emre Eşkazan

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Sara Chierchini,1 Gianluca Ingrosso,1 Simonetta Saldi,1 Fabrizio Stracci,2 Cynthia Aristei1

1Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy; 2Department of Experimental Medicine, Section of Public Health, University of Perugia, Perugia, Italy

Correspondence: Gianluca Ingrosso
Department of Surgical and Biomedical Sciences, University of Perugia, Piazza Lucio Severi 1, Perugia 06132, Italy
Tel +39-075-5783259
Fax +39-075-5783614
Email [email protected]

Abstract: Radiotherapy is one of the mainstays of cancer treatment, and about 60% of cancer patients receive this type of treatment during their course of treatment. An evident gap between optimal and actual radiotherapy utilization proportions has recently been reported, which has been ascribed to lack of referral to radiation oncology. There are many factors influencing the radiotherapy referral, including patient anxiety about toxicity, wrong perception of efficacy and side effects by physicians and patients, insufficient knowledge of referral process. These factors, defined as barriers can be categorized in health system barriers, physician and patient barriers. In the present brief narrative review, we discussed barriers to radiotherapy referral focusing on physician and patient barriers.

Keywords: radiotherapy, referral, barriers

Introduction

Radiotherapy is one of the main modalities of cancer treatment,17 and about 60% of the patients receive radiation therapy during their course of treatment.8 An evident gap between optimal and actual radiotherapy utilization has recently been reported, which has been ascribed to the lack of referral to radiation oncology. There are many factors influencing the radiotherapy referral, including patient anxiety about toxicity, wrong perception of efficacy and side effects by physicians and patients, insufficient knowledge of the referral process. These factors, defined as barriers, can be categorized in health system barriers, physician and patient barriers. In the present brief narrative review, we discussed barriers to radiotherapy referral focusing on physician and patient barriers. Recently, the Australian Collaboration for Cancer Outcomes, Research and Evaluation (CCORE) estimated that 48% of Australian cancer patients need at least one radiotherapy treatment during their course of disease9 and in Europe, it is estimated that the rate is about 51%.10 Many authors analyzed the evident gap between optimal and actual radiotherapy utilization proportions, which is unrelated to the effectiveness of RT and has been attributed to inadequacies in radiotherapy access.1012 Concerning the term “access,” Penchansky13 defined it as a multidimensional construct expressing the fit between the consumer and the health system. In the context of radiation oncology, “access” has been defined by Turnock14 as a consultation for radiotherapy. Barriers (namely anything potentially impeding access) to access in radiation oncology15 have to be analyzed in order to setup proper measures. In our review, we performed a PubMed literature search according to the Preferred Reporting Items and Meta-Analyses (PRISMA) guidelines.16 We identified articles published within the last 10 years, up to March 30, 2019, using Medline search with the following selection criteria: English language, full papers, barriers to access to radiotherapy, physician barriers and patient barriers. We reviewed the full version of each article.

Physician Barriers

Barriers (namely anything potentially impeding access) can be categorized in health system barriers, physician and patient barriers.15 Physicians have a pivotal role in referring a patient to a radiation oncologist. Generally, patients depend on their primary care physicians or other specialists to refer them for an RT opinion. There are several factors at the level of the referring clinician, which might act as barriers to referral.

In many cases, there might be a lack of referral because of insufficient knowledge of the referral process itself, which can result in suboptimal care for patients. Knowledge gaps were analyzed by Szumacher et al.17 They reported that in the region of Ontario referring physicians do not completely understand the RT referral process. Another Canadian study demonstrated that 25% of the primary care physicians had uncertainty about referral processes.18 Together with the poor knowledge of how to refer and who to refer to, the lack of formal training about radiotherapy is another issue. In a systematic review on barriers to accessing radiation therapy, Gillan et al19 analyzed the few studies on the awareness of referring physicians about radiotherapy. They demonstrated that there is a general lack of formal training, which has a major impact on physicians’ awareness of risks and benefits of radiotherapy, limiting referrals. More specifically, regarding knowledge of the importance of radiotherapy in palliative care, Halkett et al20 surveyed Australian general practitioners asking whether they would refer for palliative therapy and to which kind of therapy (radiotherapy, chemotherapy or surgery). Answers of the respondents were compared with the opinion of an expert panel of palliative care specialists, showing that agreement on the benefit of radiotherapy ranged from 31% to 80%. Other authors21 reported that in Canada less than 45% of general practitioners are aware about the effectiveness of radiotherapy in the management of brain metastases, spinal cord compressions, as well as for the treatment of bone metastases.

Knowledge of radiation therapy (its efficacy and the related toxicity) is crucial at both primary care and specialist levels. More specifically, it is very important to update health providers about the recent advances in technology, which have changed dramatically the clinical scenarios in oncology, allowing dose escalation in radiotherapy, decreasing toxicity and treatment duration with improved oncologic outcome and with less impact on patients’ quality of life. Techniques such as intensity-modulated radiation therapy (IMRT)22 or stereotactic radiotherapy5,7,23 create highly conformal dose distributions with steep dose gradients using advanced planning and treatment equipment. Eventually, image-guided radiotherapy (IGRT) permits daily target localization to guide the dose delivery.24 It is therefore crucial to raise awareness about the new tools in radiation oncology, which are radically changing treatment delivery, fractionation schemes, and clinical indication. It is to say that there is urgent need of training concerning not only recent clinical advances but also radiotherapy indications, for instance in palliative care. In fact, a survey on behalf of ASTRO (American Society for Radiation Oncology), ASCO (American Society of Clinical Oncology) and AAHPM (American Academy of hospice Palliative Medicine) among members evidenced that the lack of education and of written material about palliative radiotherapy cause the inhibition of palliative radiotherapy referral.25 Another interesting topic from this survey is the lack of communication within a multidisciplinary team. Respondents specified that increased multidisciplinary activity directly involving radiation oncologists in the treatment decision could allow educating team members about palliative radiotherapy.26 In clinical oncology, multidisciplinary team (MDT) meetings, which allow discussing clinical cases with the intervention of various specialists, might give the opportunity to overcome barriers related to gaps in knowledge and to physicians’ communication and might reduce decision biases related to the individual point of view. More specifically, the MDT might suggest to every patient the best diagnostic and/or therapeutic strategy for a personalized “iter”, which needs to be defined by different figures with specific skills that sometimes could offer competing treatments. The opportunity to discuss about every single case within the MDT might mitigate imbalances in the prescription of a single treatment option. A recent review of the literature evidence that between 4% and 45% of patients discussed at MDT meetings had a change in diagnostic reports following the meeting, and that patients were more likely to receive a more accurate treatment strategy.27 On the other hand, discrepancies exist between MDT referral. For instance, Atwell et al28 evaluated the MTD referral rates depending on the tumor type at their institution between 2010 and 2015. Regarding patients affected by prostate cancer, only 34% were discussed in the MDT. Although there should be a shared decision-making within MTDs for prostate cancer patients, it seems that the clinical “practice” is completely different from the “theory.”

Patient Barriers

Underutilization of radiotherapy seems to be associated with individual characteristics and choices of patients.2531 More specifically, barriers related to the patients seem to cluster around age, comorbidities, education level and socioeconomic status.

One of the most relevant factors as barriers to accessing to radiation therapy is the patient’s age. In the analysis by Wong et al,32 it is quite evident the age disparity with palliative radiotherapy. Using the Surveillance, Epidemiology, and End Results (SEER) database, the authors identified 63,221 patients affected by metastatic cancer in the period from 2000 to 2007, demonstrating that the use of radiation therapy decreases steadily with increasing patient age. More specifically, for the same setting of patient’s rates of palliative RT decreased from 42% for patients aged 66 to 69 to 24% for those aged 80 to 84. This kind of inverse relationship between increasing patients’ age and actual radiotherapy utilization seems to be present in the United States as in Europe, regarding palliative and radical or post-operative RT as well. In fact, a recent evaluation of the underutilization of radiotherapy in Belgium12 evidences, in the period from 2009 to 2010, an overall actual radiotherapy utilization proportion (AUP) value of 37% instead of 53% of optimal utilization proportion (OUP). The analysis of data showed the impact of patients’ age on the decision to refer to radiotherapy. For instance, among patients affected by prostate cancer, only 11% of those older than 80 years received radiotherapy compared with 31% of those younger than 80 years. Regarding breast cancer, 83% of patients younger than 80 years were irradiated instead of 36% for those older than 80 years.

Along with increasing age, also comorbidities can dramatically influence the RT referral.3335 Hayman et al36 performed a retrospective population-based cohort study analyzing the frequency of use of RT in elderly patients affected by stage IV NSCLC. At multivariate analysis, comorbidity, assessed by the Klabunde modification of the Charlson-Deyo score,3739 was associated with a significant decrease of RT use (p<0.001) in patients with a comorbidity score ≥1 compared with those with a score of 0.

Although radiotherapy as definitive (e.g. for prostate cancer40) or adjuvant treatment (e.g. for breast cancer41) might not be useful in patients with multiple comorbidities and short life expectancy, palliative RT administered for relief of symptoms might be a very useful treatment in elderly patients with high comorbidity scores. This is because RT as a palliative treatment can safely act against the symptom (i.e. pain, bleeding) or against the oligometastatic disease in a very rapid and effective way,4 reducing the load of pharmacological therapy.

Regarding education level and socioeconomic status as barriers, it is very difficult to split these two categories. Puts et al42 demonstrated that patients refusing an RT referral were mainly older and living alone. The economic impact of radiotherapy concerns not only the patient itself. There is the need of transport, and there is the loss of time and of working days, which involves the relatives (caregivers) too. Low-income patients are more likely to receive a worse health assistance, and this condition has been associated with a reduction in the use of radiotherapy and of more complex treatment modalities.30,43 For instance, in the United States, the use of cutting-edge techniques such as IMRT might often be denied during insurance appeals although some author demonstrated that insurance or socioeconomic status might not significantly correlate with IMRT delivery.44 Differences in the insurance status, which are mainly ascribable to a given health system, might influence the radiotherapy referral in certain regions, but it is very difficult to split educational level, socio-economic and insurance status. The socio-economic status and the education level of the patient have been clearly associated with an underutilization of radiation therapy.29,43,45 It can be argued that a low education level may influence the understanding and perceptions of RT. More specifically, patients with a higher education level can have easier access to accurate information on indications to treatment, modern available techniques, oncologic outcome, and expected side effects.

Conclusions

The identification of factors influencing the radiotherapy referral is the first step toward the accurate planning of measures to overcome such barriers. One of the main issues is the lack of awareness about radiotherapy.19 Moreover, advances in molecular biology and new imaging and treatment tools are rapidly changing the role of modern radiotherapy in the cure of cancer. In this scenario, it seems crucial to promote a periodic formal training in radiation oncology for the physicians, and to inform patients about the newly available treatment options explaining the indications of RT, its modalities of delivery and acute and late effects.

Considering the referral process, an insufficient knowledge of the process itself, by physicians and patients, has been reported.18 Multidisciplinary team meetings might give the opportunity to overcome barriers related to gaps in knowledge of the referral process, and to physicians’ communication. Eventually, MDT might allow the discussion between different specialists, and reduce decision biases related to the individual point of view.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Crook JM, Gomez-Iturriaga A, Wallace K, et al. Comparison of health-related quality of life 5 years after SPIRIT: surgical prostatectomy versus interstitial radiation intervention trial. J Clin Oncol. 2011;29:362–368. doi:10.1200/JCO.2010.31.7305

2. Landoni F, Maneo A, Colombo A, et al. Randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer. Lancet. 1997;350:535–540. doi:10.1016/S0140-6736(97)02250-2

3. Pignon JP, le Maître A, Maillard E, et al. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): an update on 93 randomised trials and 17,346 patients. Radiother Oncol. 2009;92:4–14. doi:10.1016/j.radonc.2009.04.014

4. Lancia A, Ingrosso G, Carosi A, et al. Oligometastatic cancer in elderly patients: the “blitzkrieg” radiotherapy approach. Aging Clin Exp Res. 2019;31:109–114. doi:10.1007/s40520-018-0937-6

5. Palma DA, Olson R, Harrow S, et al. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet. 2019;393:2051–2058. doi:10.1016/S0140-6736(18)32487-5

6. Timmerman R, Paulus R, Galvin J, et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. Jama. 2010;303:1070–1076. doi:10.1001/jama.2010.261

7. Lancia A, Ingrosso G, Carosi A, et al. Oligometastatic cancer: stereotactic ablative radiotherapy for patients affected by isolated body metastasis. Acta Oncol. 2017;56:1621–1625. doi:10.1080/0284186X.2017.1346383

8. Warren JL, Yabroff KR, Meekins A, et al. Evaluation of trends in the cost of initial cancer treatment. J Natl Cancer Inst. 2008;100:888–897. doi:10.1093/jnci/djn175

9. Barton MB, Jacob S, Shafiq J, et al. Estimating the demand for radiotherapy from the evidence: a review of changes from 2003 to 2012. Radiother Oncol. 2014;112:140–144. doi:10.1016/j.radonc.2014.03.024

10. Borras JM, Lievens Y, Dunscombe P, et al. The optimal utilization proportion of external beam radiotherapy in European countries: an ESTRO-HERO analysis. Radiother Oncol. 2015;116:38–44. doi:10.1016/j.radonc.2015.04.018

11. Borras JM, Lievens Y, Grau C, et al. The need for radiotherapy in Europe in 2020: not only data but also a cancer plan. Acta Oncol. 2015;54:1268–1274. doi:10.3109/0284186X.2015.1062139

12. Lievens Y, De Schutter H, Stellamans K, et al. Radiotherapy access in Belgium: how far are we from evidence-based utilisation? Eur J Cancer. 2017;84:102–113. doi:10.1016/j.ejca.2017.07.011

13. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19:127–140. doi:10.1097/00005650-198102000-00001

14. Turnock B. Public Health: What It Is and How It Works. 4th ed. Sudbury MA: Jones and Bartlett Publishers; 2009.

15. Sundaresan P, King MT, Stockler MR, et al. Barriers to radiotherapy utilisation in New South Wales Australia: health professionals’ perceptions of impacting factors. J Med Imaging Radiat Oncol. 2015;59:535–541. doi:10.1111/1754-9485.12334

16. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264–269.

17. Szumacher E, Barbera L, Barnes E, et al. Improving access to radiotherapy services in the Simcoe-Muskoka region of Ontario: needs assessment study. Int J Radiat Oncol Biol Phys. 2007;69:S557.

18. Samant RS, Fitzgibbon E, Meng J, et al. Barriers to palliative radiotherapy referral: a Canadian perspective. Acta Oncol. 2007;46:659–663. doi:10.1080/02841860600979005

19. Gillan C, Briggs K, Goytisolo Pazos A, et al. Barriers to accessing radiation therapy in Canada: a systematic review. Radiat Oncol. 2012;7:167.

20. Halkett GK, Jiwa M, Meng X, et al. Referring advanced cancer patients for palliative treatment: a national structured vignette survey of Australian GPs. Fam Pract. 2014;31:60–70. doi:10.1093/fampra/cmt068

21. Samant R, Fitzgibbon E, Meng J, et al. Family physicians’ perspectives regarding palliative radiotherapy. Radiother Oncol. 2006;78:101–106. doi:10.1016/j.radonc.2005.11.008

22. Staffurth J; Radiotherapy Development Board. A review of the clinical evidence for intensity-modulated radiotherapy. Clin Oncol. 2010;22:643–657.

23. Fodor A, Lancia A, Ceci F, et al. Oligorecurrent prostate cancer limited to lymph nodes: getting our ducks in a row. World J Urol. 2018. Epub ahead of print. doi:10.1007/s00345-018-2322-7

24. Dawson LA, Ménard C. Imaging in radiation oncology: a perspective. Oncologist. 2010;15:338–349. doi:10.1634/theoncologist.2009-S106

25. McCloskey SA, Tao ML, Rose CM, et al. National survey of perspectives of palliative radiation therapy: role, barriers, and needs. Cancer J. 2007;13:130–137. doi:10.1097/PPO.0b013e31804675d4

26. Boxer MM, Vinod SK, Shafiq J, et al. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer. 2011;117:5112–5120. doi:10.1002/cncr.26149

27. Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: a systematic review of the literature. Cancer Treat Rev. 2016;42:56–72. doi:10.1016/j.ctrv.2015.11.007

28. Atwell D, Vignarajah DD, Chan BA, et al. Referral rates to multidisciplinary team meetings: is there disparity between tumour streams? J Med Imaging Radiat Oncol. 2019;63:378–382. doi:10.1111/1754-9485.12851

29. Johnston GM, Boyd CJ, Joseph P, et al. Variation in delivery of palliative radiotherapy to persons dying of cancer in Nova Scotia, 1994 to 1998. J Clin Oncol. 2001;19:3323–3332. doi:10.1200/JCO.2001.19.14.3323

30. Aarts MJ, van der Aa MA, Coebergh JW, et al. Reduction of socioeconomic inequality in cancer incidence in the South of the Netherlands during 1996–2008. Eur J Cancer. 2010;46:2633–2646. doi:10.1016/j.ejca.2010.07.039

31. Stracci F, Bianconi F, Lupi C, et al. Spatial barriers impact upon appropriate delivery of radiotherapy in breast cancer patients. Cancer Med. 2018;7:370–379. doi:10.1002/cam4.1304

32. Wong J, Xu B, Yeung HN, et al. Age disparity in palliative radiation therapy among patients with advanced cancer. Int J Radiat Oncol Biol Phys. 2014;90:224–230. doi:10.1016/j.ijrobp.2014.03.050

33. Tyldesley S, Zhang-Salomons J, Groome PA, et al. Association between age and the utilization of radiotherapy in Ontario. Int J Radiat Oncol Biol Phys. 2000;47:469–480. doi:10.1016/s0360-3016(00)00440-5

34. Tyldesley S, Roques TW, Erridge S. General practitioner assessment of stage and performance status in lung cancer patients at a population level: implications for prognosis and radiotherapy needs analyses. Lung Cancer. 2007;57:381–388. doi:10.1016/j.lungcan.2007.03.024

35. Lavergne MR, Johnston GM, Gao J, et al. Variation in the use of palliative radiotherapy at end of life: examining demographic, clinical, health service, and geographic factors in a population-based study. Palliat Med. 2011;25:101–110. doi:10.1177/0269216310384900

36. Hayman JA, Abrahamse PH, Lakhani I, et al. Use of palliative radiotherapy among patients with metastatic non-small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2007;69:1001–1007. doi:10.1016/j.ijrobp.2007.04.059

37. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383. doi:10.1016/0021-9681(87)90171-8

38. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–619. doi:10.1016/0895-4356(92)90133-8

39. Klabunde CN, Potosky AL, Legler JM, et al. Development of a comorbidity index using physician claims data. J Clin Epidemiol. 2000;53:1258–1267. doi:10.1016/s0895-4356(00)00256-0

40. Potosky AL, Merrill RM, Riley GF, et al. Prostate cancer treatment and ten-year survival among group/staff HMO and fee-for-service Medicare patients. Health Serv Res. 1999;34:525–546.

41. Riley GF, Potosky AL, Klabunde CN, et al. Stage at diagnosis and treatment patterns among older women with breast cancer: an HMO and fee-for-service comparison. JAMA. 1999;281:720–726. doi:10.1001/jama.281.8.720

42. Puts MT, Monette J, Girre V, et al. Characteristics of older newly diagnosed cancer patients refusing cancer treatments. Support Care Cancer. 2010;18:969–974. doi:10.1007/s00520-010-0883-0

43. Huang J, Zhou S, Groome P, et al. Factors affecting the use of palliative radiotherapy in Ontario. J Clin Oncol. 2001;19:137–144. doi:10.1200/JCO.2001.19.1.137

44. Shaaban SG, Verma V, Choi JI, et al. Utilization of Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma in the United States. Clin Lung Cancer. 2018;19:e685–e692. doi:10.1016/j.cllc.2018.04.019

45. Fortin B. Goldberg MS, Mayo NE et al. Waiting time for radiation therapy in breast cancer patients in Quebec from 1992 to 1998: a study of surgically treated breast cancer patients in Quebec documents and helps to explain increased waiting times for radiation therapy.Healthcare Policy. 2006;1:152–167.

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