More than one-fifth of patients with metastatic cancer at the end of life received radiotherapy outside of recommended guidelines, according to a study published in JAMA Health Forum.

For this study, researchers looked at radiotherapy data from the Centers for Medicare & Medicaid Services in July 2019 for the Radiation Oncology Alternative Payment Model. The study included patients older than 65 years who died within 90 days of treatment planning.

The researchers were looking for treatment outside of guideline-concordant care, defined as a more than 10-fraction regimen or combination regimen, including conventional external beam radiotherapy in combination with stereotactic radiosurgery for brain metastases.

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The researchers analyzed 46,781 episodes. In 3.7% of these cases, the patient died within 90 days of radiotherapy. About half (51.3%) of those were for bone metastases, and the other half (48.7%) were for brain metastases.

Of the patients who died, 21.6% did not receive guideline-concordant radiotherapy.

In a multivariate analysis, factors associated with lower odds of guideline-nonconcordant care were treatment in hospital-affiliated facilities (adjusted odds ratio [aOR], 0.50; P <.001) and older age. Compared with patients ages 65-75 years, the aOR was 0.90 for patients 75-85 years and 0.73 for patients 85 years or older (P <.001).

Factors associated with greater odds of nonconcordant radiotherapy included receipt of major procedures (aOR, 1.17; P =.01) or chemotherapy (aOR, 1.26; P <.001) and survival more than 30 days after the treatment planning appointment. The aOR was 4.72 for survival 31-60 days after the appointment and 6.55 for 61-90 days (P <.001).

The researchers noted that this study is limited by its use of Medicare claims data without linkage to medical records or cancer registries.

“Our findings suggest that the burden of unnecessary radiotherapy in the metastatic setting is shared by a sizeable proportion of patients near the end of life, underscoring the importance of guideline adherence,” the researchers concluded.

Disclosures: This research was supported by funding from the National Care Network and Pfizer EMBRACE. Some study authors declared affiliations with various companies and organizations. Please see the original reference for a full list of disclosures.


Santos PMG, Mathis NJ, Lapen K, et al. Assessment of guideline-nonconcordant radiotherapy in Medicare beneficiaries with metastatic cancer near the end of life, 2015-2017. JAMA Health Forum. Published online January 14, 2022. doi:10.1001/jamahealthforum.2021.4468