Improvement of Post–Radiation Therapy Cancer Care for Veteran Patients Living in a Rural Area

  • Lee S
  • Cho-Lim J
  • Lee B
  • et al.
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may differentially increase fatigue and this study aims to characterize fatigue development in prostate cancer patients during EBRT. Materials/Methods: We identified a cohort of 681 patients with non-metastatic prostate cancer undergoing a 7-9 week course of EBRT and enrolled on our institutional patient registries. Patient fatigue scores (range 0-3; 1 Z fatigue relieved by rest; 2 Z fatigue not relieved by rest, limiting instrumental activities of daily living (ADL); 3 Z fatigue unrelieved by rest, limiting self-care ADL) were prospectively recorded at on-treatment visits by providers using NCI-CTCAE v4.0 criteria. For each patient, we recorded clinical and demographic factors including age, race, treatment modality, disease stage, Gleason score, baseline PSA level, daily treatment time, dose/fraction delivered, smoking status, Charleson-Deyo comorbidity score, employment status, body mass index and concurrent medication use. Non-parametric-means testing was employed to identify significant dif-ferences in severity of provider-recorded fatigue levels by classification category, with adjustment for baseline fatigue. Results: Significant increases in reported fatigue severity were seen in pa-tients with age <60 years (pZ0.03), advanced clinical stage (pZ0.04), androgen deprivation therapy use (pZ0.03), and genitourinary product use during EBRT (pZ0.04). The overall reported fatigue was higher with con-current medication use of anti-depressants (pZ0.04), urinary anti-spasmodics (pZ0.04), beta-blockers (pZ0.04), and narcotic analgesics (pZ0.04). Baseline clinical stage (pZ0.02), obesity (pZ0.04), and proportion of radi-ation treatments delivered in the evening (pZ0.02) were also associated with higher recorded fatigue levels throughout EBRT. No other demographic-, disease-or EBRT-related factors correlated with increased fatigue. Conclusion: This retrospective analysis of a prostate cancer patient registry with prospectively-collected fatigue scores identified that age, stage, obesity, evening treatments, and use of specific medication classes during the treatment period appeared to significantly associate with increases in reported fatigue over the EBRT course. Continued investigation is needed to further elucidate clinical drivers and biological underpinnings of increased fatigue to guide potential interventions. Purpose/Objective(s): Veteran patients who have received radiotherapy (RT) require diligent surveillance by Radiation Oncology (RO) specialists as an integral part of their cancer survivorship. This Veterans Affairs (VA) project aims to alleviate the problem of inadequate access to post-RT follow-up care for Veterans living in rural areas. Materials/Methods: A rural-outreach team of RO specialists is assembled to include clinical providers and medical physicists. Two-prong approach is employed: one by in-person visit at selected rural Community-Based Outpatient Clinic (rCBOC), the other via telehealth link. Target population includes Veterans residing in rural areas who have received RT at either a VA or Non-VA Care Center (NVCC) treatment facility. Prior RT history is reviewed before rendering patient care. On-site visits are done by RO specialists at each rCBOC semiannually. Telehealth care is provided by secured remote audiovisual connection where feasible. Patient satisfaction is evaluated via feedback survey. Mileage and time saved for each Veteran who might otherwise travel to see a VA RO specialist are calculated. Results: From September 2015 to November 2016, 9 separate rCBOC visits have been made for 3 sites and a total of 49 Veteran visits. Excellent patient satisfaction was obtained, and the average mileage and time saved per Veteran visit was 217.2 miles and 201 min (off-traffic peak), respec-tively. However, 4 of 5 NVCC treatment plans encountered contained physics quality assurance (QA) data not considered to have met professional standards. Dedicated telehealth equipment (Cisco EX90Ò) was acquired and connections validated. Challenges faced included: soliciting timely assistance of administrative leadership, identifying pa-tients to be seen and accessing their records, setting up rCBOC visits at regular interval, obtaining clinical privilege and EHR access at rCBOCs, and recruiting additional professional personnel to share the workload. Conclusion: Access to post-RT cancer care for rural Veterans can be improved with in-person visits by VA RO specialists at corresponding rCBOCs. Barriers due to distance and time can be reduced significantly, with excellent patient satisfaction outcome. The efficacy of supplementing such endeavor by telehealth link requires further clinical testing and pa-tient feedback assessment. Furthermore, the inadvertent finding of poten-tial physics QA deficiencies at NVCC sites has raised plausible concern for overall quality of RT care, reflecting the probable need for future oversight by VA. By reaching out to the Veterans in person or via telehealth, this project shows efficacious ways to enhance post-RT cancer care for Vet-erans living in rural areas, thereby improving their cancer survivorship and quality of life.




Lee, S. P. H., Cho-Lim, J. J., Lee, B. K. Y., Zhang, J., Leu, M., & Inouye, W. (2017). Improvement of Post–Radiation Therapy Cancer Care for Veteran Patients Living in a Rural Area. International Journal of Radiation Oncology*Biology*Physics, 99(2), E532.

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