Barriers to palliative radiotherapy referral: A Canadian perspective

Abstract

Radiotherapy is an effective but underutilized treatment modality for cancer patients. We decided to investigate the factors influencing radiotherapy referral among family physicians in our region. A 30-item survey was developed to determine palliative radiotherapy knowledge and factors influencing referral. It was sent to 400 physicians in eastern Ontario (Canada) and the completed surveys were evaluated. The overall response rate was 50% with almost all physicians seeing cancer patients recently (97%) and the majority (80%) providing palliative care. Approximately 56% had referred patients for radiotherapy previously and 59% were aware of the regional community oncology program. Factors influencing radiotherapy referral included the following: waiting times for radiotherapy consultation and treatment, uncertainty about the benefits of radiotherapy, patient age, and perceived patient inconvenience. Physicians who referred patients for radiotherapy were more than likely to provide palliative care, work outside of urban centres, have hospital privileges and had sought advice from a radiation oncologist in the past. A variety of factors influence the referral of cancer patients for radiotherapy by family physicians and addressing issues such as long waiting times, lack of palliative radiotherapy knowledge and awareness of Cancer Centre services could increase the rate of appropriate radiotherapy patient referral.

Radiotherapy is a well-established treatment modality in the management of many cancers [1–5]. It has an especially important role to play in the palliative setting often with clinically significant response rates of 60 – 80% [1], [3], [5]. Common indications for palliative radiotherapy include painful bone and soft tissue metastases, superior vena cava obstruction, hemoptysis, spinal cord compression and brain metastases [1]. However, published data suggests that radiotherapy is vastly underutilized in the province of Ontario (Canada), especially for palliation [6], [7]. Studies from Europe also confirm the underutilization of radiotherapy [8], [9]. In fact, it appears as though palliative radiotherapy utilization is decreasing in comparison to radical and adjuvant treatment [8], [10]. A variety of reasons for the under-utilization of radiotherapy have been suggested and speculated upon [8], [11–14], including insufficient treatment resources and inadequate knowledge of radiotherapy among referring physicians, and these are likely not the only ones responsible. However, there is very little published data actually documenting the factors influencing palliative radiotherapy referral [11], [14–16].

In 1999, the Ottawa Hospital Regional Cancer Centre (OHRCC) established a Rapid Palliative Radiotherapy Program (RPRP) in order to provide family physicians with rapid access to radiotherapy consultation and treatment for patients with advanced symptomatic cancer. A retrospective chart audit in 2002 revealed that less than a third of the patients referred to the RPRP were sent from family physicians practicing in the community. Most of the patient referrals were from specialists and only 17 family physicians in Eastern Ontario (in catchment areas served by almost 1 000 family physicians) utilized the program over a two-year period.

We were concerned about the limited use of the RPRP by family physicians in our region and decided to investigate this further. It was felt that since family physicians provided much of the care for patients with advanced cancer in the community, they should be utilizing the RPRP to a greater extent. Therefore, we proceeded to determine factors that influence family physicians to refer patients for palliative radiotherapy. The primary objective was to identify and address potential barriers to radiotherapy referral among family physicians in our region.

Methods

A seven page, 30-item questionnaire was developed at the OHRCC by a panel including a survey expert, two radiation oncologists, and a palliative care physician in order to evaluate palliative radiotherapy knowledge and factors influencing patient referral. It included the following sections: (1) respondent characteristics; (2) awareness of and perceived accessibility to oncology services at the Regional Cancer Centre; (3) factors influencing radiotherapy referral for palliation; (4) perception of the effectiveness of palliative radiotherapy; and (5) willingness to attend continuing medical education on radiation oncology. The study was designed for self-completion and required approximately 10 to 15 min.

The sample frame of family physicians in Eastern Ontario served by the Cancer Centre was compiled using the Southam Canadian Medical Directory and an OHRCC list of family physicians in the region. In total, the sample frame consisted of 997 family physicians and, in the spring of 2002, the survey was mailed to a random sample of 400 of these physicians. The responses from the completed surveys returned to the OHRCC were then analyzed. Multi-variate logistic regression modeling techniques were used to profile family physicians that referred patients for palliative radiotherapy.

Results

The survey return rate was 57% (227/400) but 55 (14%) were deemed ineligible because the physicians did not practice family medicine, did not see cancer patients or moved with no forwarding address. The overall response rate for eligible family physicians was 50% (172/345). The demographics of the respondents are shown in Table I. Almost all (97%) had recently (within the last month) seen cancer patients in their offices, with 85% caring for patients with advanced cancer and 80% providing palliative care. Fifty-six percent had referred patients for radiotherapy previously and 53% had contacted a radiation oncologist in the past for advice. Interestingly, 41% of responding family physicians were unaware of the OHRCC Community Oncology Program. Only 18% were aware of the OHRCC RPRP and even fewer (9%) had referred patients to the program. However, 51% of all respondents felt that they had seen cancer patients in the past year who could have potentially benefited from the RPRP.

Table I.  Demographics of responding family physicians.

Demographic variable	Responders%. (n = 172)
Gender
Female	44
Male	56
Year of Graduation
Mean	1980
Range	1948–1998
Years practicing Family Medicine
Mean	18 years
Range	0–40 years
CCFP*
Yes	64
No	36
Practice setting
Urban	64
Rural	36
Hospital Admitting Privileges
Yes	52
No	48

* CCFP = Certificant of Canadian College of Family.

Physicians were asked to rate the degree to which certain factors influenced their decision to refer patients for palliative radiotherapy and the results are shown in Figure 1. We found that cancer type, patient preference and performance status influenced the family physicians the most. It can be seen that patient referral was hindered (“somewhat” or “a lot”) by factors such as long waiting times for radiotherapy (55%) and uncertainty about the benefits of radiotherapy (54%). Patient age, proximity to the Cancer Centre and perceived patient convenience were influenced more than 40% of physicians when considering patient referral. Even uncertainty about the referral process and difficulty contacting a radiation oncologist or nurse at the Cancer Centre were factors influencing referral for over 25% of respondents.

Figure 1.  Factors influencing decision to refer patients for radiotherapy.

The physicians' perceptions about the effectiveness of radiotherapy are shown in Figure 2. Although most physicians were aware that radiotherapy was effective for painful bone and soft tissue metastases, brain metastases and malignant airway obstruction, more than 30% of respondents stated they did not know if radiotherapy was effective for malignant spinal cord compression, hematuria, or hemoptysis. Perceived life expectancy influenced 42% of family physicians in their decision to refer for palliative radiotherapy with over a third of them considering that patients should have a life expectancy of greater than four months prior in order to refer patients for palliative radiotherapy.

Figure 2.  Physicians’ perceptions on radiotherapy effectiveness for palliative conditions.

Family physicians more knowledgeable about the indications for palliative radiotherapy were significantly more likely (p < 0.01) to have referred patients for radiotherapy in the past. Over 85% thought they would benefit from continuing medical education on radiotherapy and would be willing to attend such a session. The preferred formats for continuing medical education were small group tutorials and workshops along with written materials.

In our survey, family physicians who referred patients for radiotherapy differ significantly (p < 0.01) from those who did not refer as shown in Table II. Specifically, referring patients were more likely to provide palliative care to their patients (96% vs. 75%), work outside of urban centres (45% vs. 25%) and had hospital admitting privileges (62% vs. 40%). Referring physicians also were more likely to have sought advice from radiation oncologists in the past than non-referring physicians (73% vs. 29%). Multivariate analysis revealed that the most important factors influencing referral to our RPRP were having previously sought advice from a radiation oncologist and providing palliative care to patients.

Table II.  Factors related to prior referral of patients for radiotherapy*.

Factors	No prior referrral %	Prior referrral %
Regularly provide palliative care?
Yes	75	96
No	25	4
Urban Practice Location?
Yes	75	55
No	25	45
Hospital Privileges?
Yes	40	62
No	60	38
Previously sought advice from radiation oncologist?
Yes	29	73
No	71	27
Considers access to radiation oncologists adequate?
Yes	35	60
No	25	32
Never tried	40	8
Considers radiotherapy effective for treating painful bony metastases?
Yes	92	99
No	8	1

* The number of physicians who provided data on each factor varied from 116 to 172.

Discussion

We were satisfied with the 50% response rate since it is higher than that found in most physician surveys [17]. We hope that the results reflect general opinion among family physicians in our region but recognize this as a limitation of our study. This study identifies many of the potential barriers to radiotherapy referral, some of which could explain the under use of radiotherapy in Ontario and elsewhere in the world. Firstly, appropriate referral for radiotherapy depends upon an appreciation of the services available and we often assume that the health care community in our region is well informed about these. Therefore, it was surprising to find out that many physicians in our region were not even away of our Community Oncology Program and very few were aware of our RPRP for patients with advanced cancer. Clearly, referrals will not be forthcoming from family physicians if information regarding available resources has not been adequately disseminated. This has, no doubt, been a factor in the small number of family physicians referring patients to the RPRP. In fact, many of the physicians thought that they had seen patients in the previous year that could have benefited from the Program had they been aware of it. Patient preference for palliative radiotherapy is a big factor in considering referral but patients will obviously rely on their family physicians to help them determine whether it is worthwhile.

Our results clearly indicate that there are a variety of factors influencing the referral of patients for palliative radiotherapy by family physicians. We believe that these findings are relevant for Canada as well as other western industrialized countries. Studies from several European countries, including Sweden, with similar health care systems and availability of resources have also identified problems related to radiotherapy referral [9], [12], [13], [18]. It has long been felt that the proximity to cancer centres, perceived patient inconvenience, and waiting times for consultation and treatment are concerns for referring doctors, and these were confirmed in our survey [6], [7], [10], [11], [19]. However, we found that other factors also have a major influence on referral. These include difficulties related to contacting oncologists and nurses at our centre along with uncertainties about the referral process itself. It was surprising to find that the proximity to the OHRCC was an issue in our region where the vast majority of patients live within a one-hour drive of the cancer treatment facilities.

Lack of education about the important role of palliative radiotherapy appears to be a major barrier to radiotherapy referral and this has been suggested elsewhere [11], [14]. Knowledge about the indications for palliative radiotherapy was correlated with referrals, so the family physicians most knowledgeable about the indications for palliative radiotherapy were also the most likely to have referred patients for radiotherapy in the past. It was also interesting to find out that factors such as patient age and cancer type influenced physicians’ decision to refer patients although there is no evidence whatsoever to suggest that these factors affect actual response rates to palliative radiotherapy [10]. The lack of radiotherapy knowledge is somewhat understandable since fewer than 20% of the physicians have received any radiotherapy education either during or following their formal medical training.

With limited health care resources, waiting times and proximity of Cancer Centres to the populations served continue to be a concern [6]. We had developed the RPRP in order to help alleviate some of these problems as well as minimizing patient inconvenience and streamlining the referral process for patients with advanced symptomatic cancer. However, we will need to properly educate and inform the physicians and other health care providers in the community first. It seems obvious that only after family physicians have been made aware of the oncology services available in the region and educated about the value of palliative radiotherapy can they begin to consider it routinely for their cancer patients. Fortunately, there seems to be a genuine desire to improve radiotherapy knowledge among the responding physicians.

Increased resources obviously need to be put in place to address the needs of cancer patients so they can be seen and treated in a timely manner. Although it takes years to increase the infrastructure resources (such as radiotherapy treatment machines and medical personnel) needed to reduce waiting times, educating family physicians and other health care professionals in the community about oncology services in general and palliative radiotherapy in particular should be more straightforward. However, it will require a concerted effort from representatives at our cancer centre, including radiation oncologists, to go into the communities they serve. The physicians in the community need to be fully aware of the cancer services available and the best means to access them. Also, oncologists need to be readily available to offer advice to referring physicians. Better communication between radiation oncologists and family physicians should lead to better care, as has been noted elsewhere [20]. The concept of an RPRP for patients with advanced symptomatic cancer is great for reducing radiotherapy waiting times and patient inconvenience but requires that the Cancer Centre have a greater presence in the community and more interaction with family doctors. We believe that our study findings may also help other cancer centers to develop strategies to improve referral rates for radiotherapy.

Conclusions

We have been able to identify and document a variety of factors influencing family physicians’ decision to refer patients with palliative radiotherapy, some of which were not obvious to us or not clearly identified in the published oncology literature. These include lack of radiotherapy knowledge, lack of awareness of available cancer services, and waiting times for consultation and treatment. Now at the OHRCC we have begun to address some of these issues, especially by having a greater radiation oncology presence in the community. Our goal is to improve our radiotherapy services in our region and increase appropriate patient referral for palliative radiotherapy.

Acknowledgements

This study was funded by a research grant from the Ottawa Regional Cancer Centre Foundation. The authors do not have any conflicts of interest to declare and did not receive any commercial or industry support.