Compliance With Radiotherapy Treatment in an Apex Cancer Center of India

Abstract

Radiotherapy (RT) plays an integral role in treatment protocols for most cancers either as a single modality or as a part of multimodal comprehensive cancer care for patients planned with curative or palliative intent. Non-compliance to planned RT treatment is associated with inferior outcomes across multiple sites. 1-4 Noncompli-ance could be the omission of RT altogether from the multimodal treatment protocol, delay in the initiation of RT, prolonged RT course because of the gap, or premature RT conclusion of RT. Compliance is also perceived as an indicator of the quality of care offered by an institute and may affect the overall oncologic outcomes. 5 The cause of noncompliance varies across institutes and regions and combines social, financial, and logistic reasons. Identifying the rate of noncompliance, its causes, and factors affecting them can help us develop an insight toward implementing mitigation measures that may contribute significantly to the quality improvement process. Our institute, Tata Memorial Center, is an apex cancer center in the country, with around 45,000 new registrations annually, and the department of radiation oncology offers RT to approximately 9,000 patients. We undertook a retrospective audit to determine the incidence of non-compliance and its causality in the patients being offered radiation therapy appointments in 2019. Patients are registered with specific Disease Management Groups managing specific tumor types and sites, undergo multidisciplinary joint clinic discussion, and are then referred for RT. Once issued an appointment (after careful evaluation of the role, efficacy, and feasibility of RT) for RT, these patients are simulated and planned for the RT treatment protocol. Counseling is done before the initiation of RT, emphasizing the efficacy of treatment and expected side effects. On-treatment patients are reviewed at least at a weekly interval to keep a check on the tolerance and response to RT. As a part of routine practice in the radiation oncology department, noncompliant patients are identified at the end of every working week, their RT charts are reviewed, and the patients are subsequently contacted and recounseled. The information gained is documented in RT charts, electronic medical records, and Radiation Oncology Information System (ROIS). Noncompliance in our study is defined as the fulfillment of any one of the criteria mentioned below: 1. Not attending the simulation for RT planning despite being scheduled for the same. 2. Planned for RT but has defaulted the starting/ini-tiation of RT treatment. 3. Received at least one or more fractions of planned RT in TMH and then defaulted the remaining planned radiation. Patients who had planned or unplanned changes in the treatment protocol (omission of RT or modification in RT plan/premature conclusion/undue gap with delayed conclusion) prescribed by the treating radiation oncologist because of toxicity or any other reason were not included in the study. In the year 2019, 45,369 patients were registered in our institute. Of the 8,607 ROIS appointments given in that year, 197 (2.28%) patients were found to be noncompliant. Of these, 112 (56.9%) were males and 85 (43.1%) were females, with a median age of 55 years (mean 52.2 years, range 8-82 years). The majority of them were married 174 (88.3%). Around one third of noncompliant patients were illiterate (33%), almost half were unemployed (53.3%), and only 9.6% had health insurance. Almost half of the noncompliant patients were from outside the state of Maharashtra (47.2%), 29.9% belonged to Mumbai (Mumbai Metropolitan Region), 18.8% were from within the state of Maharashtra, and five patients were from other countries. The mean distance between the local residence and the treating center is 20.5 km, with some patients coming from places as far as 77 km away (n = 101). Ninety-seven patients defaulted RT simulation (49.2%), 53 defaulted RT starting (26.9 %), and 47 defaulted while on RT (23.9%). Half of these had either head and neck (29.9%) or gynecologic (20.8%) malignancies. Patients with breast cancers had the least noncompliance rates (0.02%). Most of the patients had locally advanced/locoregional (136; 69%) and were planned for multimodality treatment (117; 59.4%) with either definitive chemoRT (62; 31.5%) or adjuvant RT/ChemoRT (55; 27.9%). Most of these patients were planned for external beam RT (185; 93.9%) and with curative intent (174; 88.3%). The