SIDEBAR: Value-based Effective Care 

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The study by Chen and colleagues addresses the extremely important topic of the use and delivery schedule for radiotherapy in palliation for patients with metastatic lung cancer. The number of patients who will be considered candidates for such therapy in the United States and around the world each year is substantial. The study reveals that practice is often not consistent with what is supported by level 1 evidence, and suggests that clinicians’ decisions could be influenced by financial implications. Only 6% of patients who received radiotherapy for palliation of bone metastasis were treated with a single fraction. 

Further Considerations

Obviously, each patient has individualized care needs, and multiple factors must be taken into account when deciding upon the most appropriate therapeutic regimen. Cancer treatment certainly never can be encapsulated into a “one size fits all” approach, despite what the best evidence may suggest. Patient convenience, best clinical practice (based on evidence if it’s available), and provision of value-based, effective care are concepts that need to be at the forefront of clinical management.

Cost is important, and we should decrease cost when it can be done in a way that is of no detriment to the patient. Cost comes in many forms, including system finances, patient inconvenience, patient discomfort, patient/family stress, and quality of life. The biggest cost to the patient, who may only have weeks or a few months to live, may be in the time spent traveling back and forth for multiple treatments that may not have any significantly better chance of improving palliation in comparison to a single visit. 

We all need to think more about these issues when we are asked to help a patient in need of palliative care. We have excellent evidence to help guide our decisions in palliation of metastatic disease to the bone. We need to consider each patient individually, while we also should always try to apply the best available evidence aggressively in actual clinical practice. We should make decisions that are best for the patient and economically responsible to the entire health-care system. It’s time for a change. ■

Disclosure: Dr. Wilson receives clinical research support from Merck.

Dr. Wilson is Professor, Vice Chairman and Clinical Director, and Residency Training Program Director, Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut.

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