Survival after first course of palliative radiotherapy

1. Matt Williams NCRI, Nov 2010 Matt.Williams@nhs.net Survival after first course of palliative radiotherapy

2. Background • 5 yr overall survival for cancer patients < 60%1 • Many of these die of their disease • Many of these receive palliative RT • Prognostication in end of life setting difficult • Variable access to end-of-life services 1: Rachet, Lancet Onc, 2009

3. Background • Palliative RT 40 – 50% workload of dept.2 • Effective3,4 • Cost-effective5 • Well tolerated 2: Coia, IJROBP, 1988 3: Sze, Clin. Onc., 2003 4. Lester, Cochrane DBSRev., 2006 5. Coy, IJROBP, 2000

4. Background Data on survival after palliative radiotherapy sparse

5. Background • Important, common, useful treatment modality • Could we use it as a “trigger” ? • Direct or indirect (audit) • Can we measure and monitor practice ? • SACT: Can/ Should we ask the same of RT ?

6. Background • Mount Vernon Cancer Centre • Northwest London • > 3000 new pts./ yr • 40% patients from outside MVCN

7. Methods • All patients having palliative RT at MVCC in 2005 • Who had not had previous pall RT • Palliative nature determined by clinician • Extracted their entire RT history • Chemotherapy data patchy, therefore not used • Linked with survival data & demographic data from NHS DBS • DB locked on 30.04.10

8. Methods • Excluded NMSCs • Coded treatment as being to primary/ met • If metastatic, coded site • Reduced to Brain/ Bone/ Other • Subset analysis of the 5 most common primaries • Breast, Prostate, Lung, Oes/GOJ, CUP

9. Results • 1232 patients • 1138 had died • Median age 70.5 yrs • 136 patients had previous radical/ adjuvant RT • 5 most common types 920 pts. • Median OS 5.2 months

10. Overall Survival from treatment

11. Survival of cohort No difference based on Age, SE Quintile or Primary vs. Met Group n Median OS p Primary 501 6 0.5 Metastasis 719 4.6 Brain 143 2.3 <0.000001 Other 90 4.4 Bone 486 6.3 NA 12 Treat. Free interval > 12 102 10.6 0.009 0-12 34 3.7

12. Survival by primary tumour Breast Prostate CUP Lung Oes/ GOJ Surviving Fraction Time from first treatment in Months

13. Survival for 5 primary sites Group n Median OS p All 5 920 5.4 Breast 228 11.5 Prostate 161 8.6 < 0.00001 Oesophagus 89 4.6 Lung 391 4.0 CUP 51 2.8 Results on survival by site of RT similar to entire cohort

14. Relative risks for different groups Group Hazard Ratio 95% CI Breast/ Prostate 1.0 Lung/CUP/Oes 1.98 1.67 – 2.35 Primary 1.0 Brain 1.72 1.38 - 2.15 Bone 1.22 1.01 - 1.46 Other 1.34 0.98 - 1.83

15. Summary Survival Data Group Breast/Prostate Lung/Oes/CUP N OS N OS Primary 51 15.3 320 5.2 Brain 36 3.4 70 2.1 Bone 276 11.3 109 2.4 Other 14 4.8 32 2.1 Site of metastasis matters, but only for breast/ prostate

17. Discussion • Median OS ~ 5/12‏ • Suggests could be used as a “trigger” • DS 1500, Comm. PC, ACP directive • Useful patterns of difference • Brain mets • Site of met matters in breast/ prostate • 13% patients die at 30/7 • 2% at 7/7, 6% at 14/7

18. Discussion • Illustrates use of routine data • Simple, available data • Worse OS than often quoted in trials • Different group of patients

19. Previous Work • Multiple Palliative prognosis scores • Radiotherapy: very limited work • Papers from RRRP (Ontario)6,7 • 395 pts. (total: 1308) • Primary tumour site • Bone/ non-bone • KPS‏ 6: Chow, IJROBP, 2002 7: Chow, JCO, 2008

20. Future Work • Predicting early death • Patterns of further treatment • Does it identify need ? • Early pilot at RFH • Incorporate other treatments • Currently working on lung cancer dataset

21. Conclusions • Median OS ~ 5/12 • Differences in different subgroups • Site of mets matter for breast & prostate • 13% die at 30 days • Large amount of routine data • This is only one use of it

22. Thanks David Woolf Ajoke Obilade David Greenberg & Karen Wright (ECRIC)‏ Jane Maher, Jeanette Dickson, Rob Hughes, Peter Hoskin

23. Questions ?