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  Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 55  |  Issue : 2  |  Page : 166-169
 

Compliance to radiotherapy: A tertiary care center experience


1 Department of Radiotherapy, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Radiation Oncology, Shalby Hospital, Jaipur, Rajasthan, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Kartick Rastogi
Department of Radiotherapy, SMS Medical College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_517_17

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 » Abstract 


CONTEXT: The most commonly prescribed conventional fractionation radiotherapy uses 1.8–2.2 Gy per fraction for five fractions in a week. Many times, unwanted interruptions are encountered, which ultimately affect the local control and overall survival. AIMS: The present retrospective study was carried out to study the compliance to radiotherapy at our institute and to determine various factors related to it. PATIENTS AND METHODS: The present retrospective study was carried out at the department of Radiotherapy, SMS Medical College and attached group of hospitals, Jaipur; in patients who were treated with curative intent with conventional fractionation radiotherapy over telecobalt machine from January 2017 to April 2017. Noncompliance was studied for association with various factors such as age, sex, site of primary disease, stage of tumor, distance patients had to travel to receive treatment, administration of concurrent chemotherapy, and financial burden of the treatment. RESULTS: Of 203 patients, 138 were of head-and-neck cancer, 42 of cervical cancer, and 23 of breast cancer. The cumulative incidence of noncompliance was 12.8% (15.9% for head-and-neck cancer, 7.2% for cervical cancer, and 4.4% for breast cancer). Statistically significant association was found between noncompliance and higher age of the patients (P = 0.07), male gender (P = 0.002), advanced stage (P = 0.004), administration of concurrent chemoradiotherapy (CCRT) (P < 0.001), and greater distance patients had to travel for radiotherapy (P = 0.03). CONCLUSIONS: The factors with which noncompliance is significantly associated in the present study are higher age, male gender, advanced stage of tumor, administration of CCRT, and greater distance patients had to travel to avail radiotherapy.


Keywords: Breast cancer, cervix cancer, head, neck cancer, noncompliance, radiotherapy


How to cite this article:
Gupta S, Rastogi K, Bhatnagar AR, Singh D, Gupta K, Choudhary AS. Compliance to radiotherapy: A tertiary care center experience. Indian J Cancer 2018;55:166-9

How to cite this URL:
Gupta S, Rastogi K, Bhatnagar AR, Singh D, Gupta K, Choudhary AS. Compliance to radiotherapy: A tertiary care center experience. Indian J Cancer [serial online] 2018 [cited 2019 Mar 25];55:166-9. Available from: http://www.indianjcancer.com/text.asp?2018/55/2/166/249201





 » Introduction Top


Radiotherapy is the branch of medicine, which deals with the use of ionizing radiation to treat various malignant and some benign disorders.[1] Now, its domain has expanded to treat functional disorders also. The basic principles of radiotherapy lie in the famous four R's of radiobiology, that is, repair, repopulation, redistribution, and reoxygenation.[2],[3] This forms the basis of fractionation. The most commonly prescribed conventional fractionation uses 1.8–2.2 Gy per fraction for five fractions in a week. However, this is not the true scenario. Many times, unwanted interruptions are encountered, either due to technical breakdown of the machine or treatment-related toxicities; sometimes patients do not show up again for radiotherapy. Various reasons account for this, some of which are social taboos, religious customs, myths about radiotherapy, financial constraints, alternative medicine treatment, etc. This ultimately affects the local control and overall survival.[4]

The previous two decades have experienced drastic changes in the technology of delivering radiation. The technology has moved from conventional two-dimensional radiotherapy to particle beam therapy.[5] However, a large number of cancer patients in our country still seek treatment over telecobalt machine owing to high cost of treatment on sophisticated machines. S.M.S. Medical College and Hospital is a tertiary cancer center that caters patients not only from whole of the state but also from neighboring states. Not infrequently, we encounter patients attending our outpatient department with advanced form of disease. On obtaining careful history, many among them reveal a history of previous radiotherapy but with incomplete course. Hence, the present retrospective study was carried out to study the compliance to radiotherapy at our institute and to determine various factors related to it.


 » Patients and Methods Top


During January 2017 to April 2017, we retrospectively evaluated the radiotherapy records of those patients who were treated with curative intent with conventional fractionation over telecobalt machine at department of Radiotherapy, SMS Medical College and attached group of hospitals, with the expected treatment both starting and finishing between January and April 2017. The patients whose treatment was started during this period but was expected to complete later and vice versa were excluded. The patients who were treated with palliative intent were also excluded. A total of 203 patients were found eligible. Their records were analyzed for compliance to the treatment protocol.

Compliance was defined as completion of prescribed dose of radiation during the prescribed time frame. Noncompliance was defined as the premature termination of the planned treatment by the patient without consultation or recommendation from the treating clinician. The usual dose prescription was 66–70 Gy for head-and-neck cancer, 50 Gy for breast cancer, and 50 Gy of external beam radiation for cervical cancer. Dose was delivered with 2 Gy per fraction for five fractions in a week. Compliance was studied for association with various factors such as age, gender, site of primary disease, distance patients had to travel to receive treatment, administration of concurrent chemotherapy, and financial burden of the treatment.

For statistical analysis, all data were recorded and analyzed on Microsoft Excel 2007 and Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM Corp., Armonk, New York, USA). Chi-square test was used for all categorical data. P value reports were two tailed and an alpha level of 0.05 was used to assess statistical significance.


 » Results Top


The baseline patient, tumor, and treatment characteristics are shown in [Table 1]. Of 203 patients, 138 were of head-and-neck cancer, 42 of cervix cancer, and 23 of breast cancer. The cumulative incidence of noncompliance was 12.8% (26 of 203); 15.9% of head-and-neck cancer patients, 7.2% of cervix cancer patients, and 4.4% of breast cancer patients were noncompliant. Various factors associated with noncompliance are shown in [Table 2]. Statistically significant association was found between noncompliance and higher age of the patients (P = 0.07), male gender (P = 0.002), advanced stage (P = 0.004), administration of concurrent chemoradiotherapy (CCRT) (P < 0.001), and greater distance patient had to travel for radiotherapy (P = 0.03); whereas no association was found between noncompliance and primary site of the tumor and bearing cost of the treatment. The most common cause of noncompliance was treatment-related toxicities followed by lack of communication between patient and the treating clinician while the radiotherapy was going on. The most common point of leaving radiotherapy in between was after receiving 44 Gy of radiation in case of head-and-neck cancer when boost was required to be done, most of the patients thought that their treatment had been completed. In case of cervical cancer, the most common point of discontinuing radiation was after completion of external beam radiation; most of the noncompliant patients did not go for brachytherapy.
Table 1: Baselines characteristics of the entire cohort

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Table 2: Factors affecting compliance

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 » Discussion Top


Radiation remains an integral part of management for most of the solid tumors. It may either be definitive, neoadjuvant, adjuvant, or palliative. The basic understanding of radiobiology clubbed with the recent advances of technologies has evolved in the development of altered fractionations to keep the overall treatment time short, like in continuous hyperfractionated accelerated radiotherapy for lung cancer and stereotactic body radiotherapy for tumors of central nervous system and lung. Various trials are going on to analyze the effects of hypofractionated radiotherapy in cancers of breast, prostate, brain, and head and neck. With such short course of treatment, it has also been noticed that the compliance rate of patients to the radiotherapy has increased.[6],[7],[8],[9]

Squamous cell carcinoma (SCC) of the head and neck is a locoregional disease; distant metastases are rarely seen at diagnosis. Radiotherapy and surgery are thus the treatment of choice depending on the anatomical site of tumor; surgery is preferred for early-stage carcinomas of oral cavity and maxillary sinus whereas CCRT is preferred for tumors located in nasopharynx, oropharynx, and hypopharynx. CCRT is the treatment modality if organ preservation is required. A number of studies have tested altered fractionation in head-and-neck cancer patients. Hansen et al. have shown that prolongation of the overall treatment time only leads to reduced locoregional control in well-to-moderately differentiated SCC of the head and neck.[10] Overgaard et al. have shown the importance of overall treatment time for the response to radiotherapy in patients with SCC of the head and neck.[11],[12] They concluded that the locoregional control rate, the disease-specific survival, and overall survival have significant dependency on the overall treatment time. The most beneficial results are achieved when this is short. Mohanti et al. analyzed 2,167 head-and-neck cancer patients and found that only 56% of patients complied with the prescribed treatment; compliance was maximum with patients treated with curative intent.[13] Sharma et al. studied compliance in 47 elderly head-and-neck cancer patients and found 62% patients compliant to the prescribed treatment.[14] They found that compliance to therapy was not significantly associated with advanced stage, poor general condition, intent of treatment, or presence of comorbidity. Majority (14/18) of the elderly patients showed mid-course treatment noncompliance. Pandey et al. studied 324 patients of head-and-neck cancer treated with radical radiotherapy and found 76 patients to have discontinued treatment.[15] There was no predilection for treatment noncompliance with regard to patient age, educational status, religion, site of the disease, and use of neoadjuvant or concurrent chemotherapy. There tended to be a higher association of treatment noncompliance among patients residing >100 km away from the treatment center, patients without the below poverty line card, unemployed patients, and patients with stage IV-A/B disease.

Similar studies have been done for breast cancer patients also. Badakhshi et al. have studied compliance in 1903 breast cancer patients and found significant correlation between noncompliance and patient's age, adjuvant hormonal therapy (97.0%), and adjuvant chemotherapy (96.8%).[16] Noncompliant patients had suffered a 5.02-fold increased risk of local recurrence than compliant patients that was significant. Yerushalmi and Gelmon retrospectively compared clinical and pathological features and outcomes of breast cancer patients who were compliant to recommended radiation, chemotherapy, and hormonal therapies to those who were noncompliant.[17] They found that noncompliance rates for chemotherapy, radiation, and tamoxifen were 7%, 4%, and 37%, respectively. Old age was associated with noncompliance to chemotherapy and radiation, but younger women were more often noncompliant to tamoxifen. Also, noncompliance with chemotherapy or radiation did not significantly affect 5-year local and distant disease-free survival rates whereas noncompliance with tamoxifen was associated with decreased 5-year local and distant disease-free survivals (P < 0.001).

In case of cervical cancer, the American Brachytherapy Society recommends keeping the total treatment duration to <8 weeks, that is, 56 days.[18] In a study, Chumworathayi et al. have found 100% completion of chemotherapy but with delay in 30.3% cycles in the 3 weekly group and 12.9% cycles delay in the weekly group, which was not significant.[19] In their study, they have found that all patients completed their radiotherapy within time, the time frame in their study to complete radiotherapy was 10 weeks, which was higher than the recommendations.


 » Conclusions Top


The noncompliance rate to radiotherapy in the present study is consistent with most of the studies cited in literature. The factors with which noncompliance is significantly associated in the present study are higher age, male gender, advanced stage of tumor, administration of CCRT, and greater distance patients had to travel to avail radiotherapy. The present study has included head and neck, breast, and cervix cancer patients in the same cohort irrespective of their age, which makes it different from most of the previously reported studies. Retrospective nature and small number of patients are the major limitations of the present study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Withers HR, Peters LJ. Biological aspects of radiation therapy. In: Fletcher GH, editor. Textbook of Radiotherapy. 3rd ed. Philadelphia: Lea & Febiger; 1980. p. 103-80.  Back to cited text no. 1
    
2.
Withers HR. The four R's of radiotherapy. In: Lett JT, Alder H, editors. Advances in Radiation Biology. Vol. 5. New York: Academic Press; 1975. p. 241-71.  Back to cited text no. 2
    
3.
Steel GG, McMillan TJ, Peacock JH. The 5 R's of radiotherapy. Int J Radiat Biol 1989;56:1045-8.  Back to cited text no. 3
    
4.
Mackillop WJ, Bates JH, O'Sullivan B, Withers RH. The effect of delay in treatment on local control by radiotherapy. Int J Radiat Oncol Biol Phys 1996;34:243-50.  Back to cited text no. 4
    
5.
Bucci MK, Bevan A, Roach M. Advances in radiation therapy: Conventional to 3D, to IMRT, to 4D, and beyond. CA Cancer J Clin 2005;55:117-34.  Back to cited text no. 5
    
6.
Withers HR. Biologic basis for altered fractionation schemes. Cancer 1985;55:2086-95.  Back to cited text no. 6
    
7.
Withers HR. Radiation biology and treatment options in radiation oncology. Cancer Res 1999;59:1676s-84s.  Back to cited text no. 7
    
8.
Bernier J, Horiot JC. Altered-fractionated radiotherapy in locally advanced head and neck cancer. Curr Opin Oncol 2012;24:223-8.  Back to cited text no. 8
    
9.
Barendsen GW. Dose fractionation, dose rate and iso-effect relationships for normal tissue responses. Int J Radiat Oncol Biol Phys 1982;8:779-90.  Back to cited text no. 9
    
10.
Hansen O, Overgaard J, Hansen HS, Overgaard M, Höyer M, Jörgensen KE, et al. Importance of overall treatment time for the outcome of radiotherapy of advanced head and neck carcinoma: Dependency on tumour differentiation. Radiother Oncol 1997;43:47-51.  Back to cited text no. 10
    
11.
Overgaard J, Alsner J, Eriksen J, Horsman MR, Grau C. Importance of overall treatment time for the response to radiotherapy in patients with squamous cell carcinoma of the head and neck. Rays 2000;25:313-9.  Back to cited text no. 11
    
12.
Thames HD, Bentzen SM, Turesson I, Overgaard M, Van den Bogaert W. Time-dose factors in radiotherapy: A review of the human data. Radiother Oncol 1990;19:219-35.  Back to cited text no. 12
    
13.
Mohanti BK, Nachiappan P, Pandey RM, Sharma A, Bahadur S, Thakar A. Analysis of 2167 head and neck cancer patients' management, treatment compliance and outcomes from a regional cancer centre, Delhi, India. J Laryngol Otol 2007;121:49-56.  Back to cited text no. 13
    
14.
Sharma A, Madan R, Kumar R, Sagar P, Kamal VK, Thakar A, et al. Compliance to therapy-elderly head and neck carcinoma patients. Can Geriatr J 2014;17:83-7.  Back to cited text no. 14
    
15.
Pandey KC, Revannasiddaiah S, Pant NK. Evaluation of factors in relation with the non-compliance to curative intent radiotherapy among patients of head and neck carcinoma: A Study from the Kumaon region of India. Indian J Palliat Care 2015;21:21-6.  Back to cited text no. 15
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16.
Badakhshi H, Gruen A, Sehouli J, Budach V, Boehmer D. The impact of patient compliance with adjuvant radiotherapy: A comprehensive cohort study. Cancer Med 2013;2:712-7.  Back to cited text no. 16
    
17.
Yerushalmi R, Gelmon KA. Noncompliance with adjuvant radiation, chemotherapy, or hormonal therapy in breast cancer patients. Breast Dis 2009;20:197-8.  Back to cited text no. 17
    
18.
Nag S, Erickson B, Thomadsen B, Orton C, Demanes JD, Petereit D. The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2000;48:201-11.  Back to cited text no. 18
    
19.
Chumworathayi B, Suprasert P, Charoenkwan K, Srisomboon J, Phongnarisorn C, Siriaree S, et al. Weekly versus three-weekly cisplatin as an adjunct to radiation therapy in high-risk stage I-IIA cervical cancer after surgery: A randomized comparison of treatment compliance. J Med Assoc Thai 2005;88:1483-92.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2]



 

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