Ruchika Gutt is a Radiation Oncologist at the Washington DC VA Medical Center (VAMC). Sheetal Malhotra is an Endocrinologist at The Southeast Permanente Medical Group in Jonesboro, Georgia.Drew Moghanaki is a Radiation Oncologist at the Atlanta VAMC in Georgia. Alice Cheukis aRadiation Oncologist at the James J. Peters VAMC in the Bronx, New York, and an Assistant Professor at Mount Sinai School of Medicine. Lori Hoffman-Hogg is National Program Manager for Prevention Policy at Veterans Health Administration National Center for Health Promotion and Disease Prevention in Durham, North Carolina. Maria Kelly and George Dawson are Radiation Oncologists at the New Jersey VA Health Care System in East Orange. Helen Fosmire is Deputy Chief of Staff at the Richard L. Roudebush VAMC in Indianapolis, Indiana. Correspondence: Ruchika Gutt (ruchika.gutt@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest for 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 US Government, or any of its agencies.
Background: Radiotherapy plays an important role in the palliation of lung cancer, which is the second most common cancer diagnosed in the Veterans Health Administration (VHA). The American Society for Radiation Oncology (ASTRO) developed evidenced-based treatment guidelines for the management of patients with metastatic lung cancer.
Methods: In May 2016, an electronic survey of 88 VHA radiation oncologists (ROs) was conducted to assess metastatic lung cancer management. Demographic information was obtained and 2 clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or yttrium aluminum garnet (YAG) laser technology. Survey results were assessed for concordance with published ASTRO guidelines.
Results: The survey response rate was 61%, with 93% of the 40 VHA radiation departments represented. Among respondents, 96% were board certified, and 90% held academic appointments. 88% were familiar with ASTRO guidelines. Preferred fractionation schemes were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%). The vast majority (98%) did not recommend concurrent chemotherapy for palliation. In the setting of bronchial obstruction with lung collapse, about half (49%) recommended EBB or YAG lung reexpansion before external beam radiotherapy. A minority of respondents use stereotactic body radiotherapy or EBB for palliation.
Conclusion: Most respondents demonstrated up-to-date knowledge of current evidence-based treatment guidelines. We found no distinction in clinical decisions based on demographic profiles.
Lung cancer is the leading cause of cancer mortality both in the US and worldwide.1 Many patients diagnosed with lung cancer present with advanced disease with thoracic symptoms such as cough, hemoptysis, dyspnea, and chest pain.2-4 Palliative radiotherapy is routinely used in patients with locally advanced and metastatic lung cancer with the goal of relieving these symptoms and improving quality of life. Guidelines published by the American Society for Radiation Oncology (ASTRO) in 2011, and updated in 2018, provide recommendations on palliation of lung cancer with external beam radiotherapy (EBRT) and clarify the roles of concurrent chemotherapy and endobronchial brachytherapy (EBB) for palliation.5,6
After prostate cancer, lung cancer is the second most frequently diagnosed cancer in the Veterans Health Administration (VHA).7 The VHA consists of 172 medical centers and is the largest integrated health care system in the US. At the time of this study, 40 of these centers had onsite radiation facilities. The VHA Palliative Radiation Taskforce has conducted a series of surveys to evaluate use of palliative radiotherapy in the VHA, determine VHA practice concordance with ASTRO and American College of Radiology (ACR) guidelines, and direct educational efforts towards addressing gaps in knowledge. These efforts are directed at ensuring best practices throughout this large and heterogeneous healthcare system. In 2016 a survey was conducted to evaluate concordance of VHA radiation oncologist (RO) practice with the 2011 ASTRO guidelines on palliative thoracic radiotherapy for non-small cell lung cancer (NSCLC).
