Radiation treatment dropouts-Pitfalls and solutions: A retrospective observational study

© 2023 Cancer Research, Statistics, and Treatment | Published by Wolters Kluwer - Medknow
224
Original Article: Real World Data
ABSTRACT
Background: Interruptions in radiation treatment are known to have a deleterious effect on oncologic outcomes,specifically, an increase in
tumor recurrence and decrease in cancer cure rate.
Objectives: Our primary aim was to determine the factors influencing radiotherapy interruptions and provide solutions to decrease these
dropouts.
Materials and Methods: This was a retrospective observational study conducted between May 2009 and July 2010 at Mahatma Gandhi
Cancer Hospital and Research Institute, a tertiary cancer center in Vishakhapatnam, Andhra Pradesh, India, on patients with histopathologically
provencancer,whowerereceivingradiation,eitherasdefinitiveconcurrentchemoradiationorintheadjuvantorpalliativesetting.Beforethestartand
during treatment, patients were counseled by radiation oncologists, radiation coordinators, and radiation therapy technologists.During radiotherapy,
an interruption of more than five consecutive days was considered a treatment interruption.Following a treatment interruption, patients were called
on the telephone, counseling was done, and the cause of the treatment interruption was recorded and attempts were made to resolve the problem.
Results: We enrolled 1200 patients in the study.There were more male (n = 724 [60.4%]) than female (n = 476 [39.6%]) patients.The cohort
included 379 patients (31.6%) with carcinoma of the head-and-neck and 301 patients (25.1%) with gynecological malignancies. There were
100 (8.3%) treatment interruptions recorded during the study period. The common causes of radiation interruption were radiation‑induced
toxicity (n = 20 [20%]), patient death (n = 15 [15%]), financial (n = 15 [15%]), and social (n = 12 [12%]) issues.After counseling over the telephone,
treatment could be restarted in 25 (25%) of the 100 patients who had interrupted and stopped radiotherapy.
Conclusion: Treatment interruption is relatively common in
our patients receiving radiotherapy. To prevent such dropouts and
increasecompliancetotreatment,adequateandfrequentcounseling
before and during radiation treatment is needed.
Keywords: Counseling, dropouts, radiotherapy,
treatment compliance, treatment interruption
INTRODUCTION
Radiotherapy is an integral part of the treatment paradigm
in oncology. Radiation is administered in various
settings, including radical, neoadjuvant, or adjuvant
to surgery and/or with concurrent chemotherapy. The
aim of radiation is to increase tumor control with
minimal complications. It is important to deliver the
planned radiation dose in the planned time frame.[1]
Tumor control and thereby survival depend on the total
radiation dose delivered and the number of days in which
Radiation treatment dropouts-Pitfalls and solutions: A
retrospective observational study
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How to cite this article: Patro KC, Avinash A, Bhattacharyya PS,
Pilaka VK, Muvvala M, Atchaiyalingam M, et al. Radiation treatment
dropouts-Pitfalls and solutions: A retrospective observational study. Cancer
Res Stat Treat 2023;6:224-31.
Submitted: 29‑Jan‑2023 Revised: 17‑Jun‑2023
Accepted: 18‑Jun‑2023 Published: 02-Aug-2023
Kanhu Charan Patro, Ajitesh Avinash1
,
Partha Sarathi Bhattacharyya,
Venkata Krishna Reddy Pilaka,
Mrutyunjayarao Muvvala,
Mohanapriya Atchaiyalingam,
Keerthiga Karthikeyan,
Kaviya Lakshmi Radhakrishnan,
Muralikrishna Voonna2
Departments of Radiation Oncology, 2
Surgical Oncology,
Mahatma Gandhi Cancer Hospital and Research Institute,
Visakhapatnam, Andhra Pradesh, 1
Department of Radiation
Oncology, SUM Ultimate Medicare, Bhubaneswar, Odisha, India
Address for correspondence: Dr. Kanhu Charan Patro,
Department of Radiation Oncology, Mahatma Gandhi Cancer
Hospital and Research Institute, Visakhapatnam ‑ 530017,
Andhra Pradesh, India.
E‑mail: drkcpatro@gmail.com
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Patro, et al.: Interruptions in radiation treatment: Causes and solutions
Cancer Research, Statistics, and Treatment / Volume 6 / Issue 2 / April-June 2023
the treatment is delivered, that is, the overall treatment
time (OTT).[2]
Radiation is usually delivered on a five‑days‑a‑week schedule
completed within a certain predetermined number of
weeks.[1]
However, unplanned interruptions may occur during
the predefined treatment schedule that are termed treatment
dropouts. This is a common phenomenon, particularly in
busy radiation centers and in large academic institutions.
Interruptions or dropouts in radiotherapy have a deleterious
effect in the form of decreased locoregional control due to
tumor repopulation.[3,4]
A treatment break of even a single
day in head-and-neck cancers can result in a decrease in local
control by 1.4%.[4]
McCloskey et al., in their study on patients
with head-and-neck cancers treated with definitive concurrent
chemoradiotherapy, showed that locoregional failure was more
in patients who had an interruption of radiation treatment of
more than a week as compared to those who had no treatment
breaks.[5]
According to the American Brachytherapy Society, the
total treatment duration for cervical cancer (including external
beam radiotherapy and brachytherapy) should be limited to
eightweeks.[6]
Prolongationof theOTTforcervical cancerleads
to a daily decrease of 0.6–1% in local control.[6]
It therefore becomes important to quantify treatment
interruptions in practice, to characterize the reasons for
the interruptions, and to provide solutions. We therefore
conducted this study to understand the reasons for radiation
treatment interruptions at our center, and to formulate
possible solutions that could help in decreasing the
occurrence of treatment dropouts.
MATERIALS AND METHODS
General study details
This was a retrospective observational study conducted at
the Mahatma Gandhi Cancer Hospital and Research Institute,
a tertiary cancer center in Vishakhapatnam, Andhra Pradesh,
India; analysis was performed in November 2022 for the
study conducted between May 2009 and July 2010. As it was
a retrospective analysis, ethical committee clearance was not
required as per our institutional guidelines. Additionally, as it
was a retrospective study, written informed consent could not
be obtained, and this was not necessary as per the institutional
guidelines. The study was conducted according to the ethical
guidelines established by the Declaration of Helsinki and Good
Clinical Practice Guidelines. The study was not registered with
a public clinical trials registry, as it was not an interventional
clinical trial. No funding was received for this study.
Participants
We included patients with biopsy‑proven cancer who received
radiation treatment as radical concurrent chemoradiotherapy,
adjuvant, or palliative therapy depending upon the indications
and site of tumor, and had been treated at our center during
the study period. We excluded patients whose medical records
did not contain complete biopsy and treatment reports.
Aims/objectives
Our primary objective was to determine the frequency
of radiation treatment interruptions and the factors that
predisposed to these interruptions and to propose solutions.
PUTTING IN PERSPECTIVE
Central question
• What are the causes of radiotherapy treatment interruptions?
Key findings
• 100 of 1200 (8.3%) patients had radiation treatment interruptions or dropouts.
• The main causes of radiation treatment interruptions were radiation reactions or toxicity (20 [20%]), death (15 [15%]),
progressive disease (10 [10%]), financial constraints (15 [15%]), social issues (12 [12%]), referral misguidance (9 [9%]),
mistaken satisfaction due to treatment response and impression by the patient or caregiver that the disease had been
cured early (6 [6%]), non-compliance (7 [7%]), and change in radiation plan (6 [6%]).
• There were no radiation interruptions due to machine breakdown during the study.
• Counseling at three different levels, that is, by the radiation oncologist (level I), radiation counselor (level II), and radiation
therapy technologist (level III), was implemented in an attempt to increase the treatment compliance of patients.
• Treatment could be restarted in 25 (25%) patients of a total of 100 dropouts, after counseling.
Impact
• Apart from counseling, various other issues such as financial support, motivating patients to continue despite radiation
reactions, educating non‑oncology physicians regarding treatment compliance, and resolving machine breakdown need
to be addressed to further decrease these dropouts.
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Study methodology
Eligible patients were identified from the medical records
section of our institute. The complete demographic data of
the eligible patients including clinical details, sex, primary
site, treatment interruption, and duration were collected
from the clinical case records. The data were carefully
checked for quality to ensure completeness and accuracy. We
did not collect or record any personal identification data of
the patients. As part of routine care, patients were discussed
in the multidisciplinary tumor board and were then planned
for radiation therapy. The radiation dose and fractionation
used at various tumor sites are depicted in Table 1.
Counseling of patients was performed at three levels during
various stages of radiation delivery—level I by the radiation
oncologist, level II by the radiation coordinator or counselor,
and level III by the radiation therapy technologist. During
the initial visit, the radiation oncologist (level I) counseled
the patients and their attendants regarding all aspects of
radiation—starting from the simulation process, treatment
initiation and continuation, probable side-effects and their
management, and prognosis of the disease. Thereafter,
patients and their attendants were again counseled by the
radiation coordinator or counselor (level II) regarding the
various steps of the radiation process, that is, simulation,
treatment start, and possible side-effects. On the day of
the start of radiation treatment, the radiation therapy
technologist (level III) counseled the patients and their
attendants regarding the treatment process. A specific time
slot was allotted to each patient to avoid unnecessary waiting
for radiation delivery.
During the radiation treatment, patients were reviewed once
a week by the radiation oncologist to evaluate and treat the
side-effects of radiation. Counseling was done regarding
the importance of treatment continuation and the possible
consequences of discontinuation, that is, recurrence of
disease.
Missing treatment for more than five consecutive
days (excluding weekends and public holidays) during
radiation therapy was labeled as radiation treatment
interruption or dropout. Patients who had treatment
interruptions were called on the telephone and efforts were
made to determine the cause, followed by counseling to solve
the problem and resume treatment. The causes of treatment
interruption were recorded under the following headings:
death, misguidance by non‑oncology physicians (sometimes
patients were referred to non‑oncology doctors for
management of comorbidities, and these physicians, due
to lack of knowledge, occasionally misguided the patients,
telling them that the radiation treatment was completed),
financial problems, false sense of patient satisfaction (rapid
tumor regression during radiation treatment, which
sometimes led patients to assume that the disease was cured
early), old age, comorbidity, or social issues, progressive
disease, change in treatment, toxicity, patient frustration due
to machine breakdown (occasionally leading to permanent
discontinuation of radiation), or non-compliance with the
radiation treatment schedule.
Statistics
As this was a retrospective study, we did not calculate
the sample size a priori. We included all eligible patients
during the study period. Statistical analysis was performed
in the Statistical Package for the Social Sciences (SPSS)
software (IBM Corp. Released 2012. IBM SPSS Statistics
for Windows, Version 21.0. Armonk, NY: IBM Corp.). We
performed simple descriptive statistics and represented the
data in the form of numbers and percentages. We did not
perform any tests for statistical significance.
RESULTS
Of 1378 patients screened over the 15 months period, that
is, from May 2009 to July 2010, 1200 were included as the
final study population [Figure 1].
Among the 1200 patients who started radiation, there
were 724 (60.4%) male patients; 379 (31.6%) patients
had head-and-neck malignancies. The vast majority of
patients were receiving therapy with curative intent (1142,
95.2%) [Table 2]. Of the 1200 patients who started radiation,
100 patients (8.3%) stopped radiation in the midst of
treatment (termed as dropouts), as shown in Table 3. The
top three causes for dropouts included radiation toxicity (20,
20%), death due to various causes such as toxicity, disease
progression, or other reasons like infections (15, 15%), and
financial issues (15, 15%). After counseling all the 100 patients
who had treatment interruptions, treatment was restarted
Table 1: Fractionation sizes for various sites of radiation
treatment received by patients enrolled in the study on
radiation interruptions
Tumor site Fractionation
size
Radiotherapy only or
concurrent chemoradiotherapy
Head-and-neck 1.8–2 Gy/fraction Concurrent chemoradiotherapy
Brain 1.8–2 Gy/fraction Concurrent chemoradiotherapy
Breast 1.8–2 Gy/fraction Radiotherapy
Gynecological 1.8–2 Gy/fraction Concurrent chemoradiotherapy
Gastrointestinal 1.8–2 Gy/fraction Concurrent chemoradiotherapy
Genitourinary 1.8–2 Gy/fraction Concurrent chemoradiotherapy
Palliative radiation
(various sites)
3 Gy/fraction Radiotherapy
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in 25 (25%) patients, that is, one‑quarter of the total number
of dropouts. The other 75 (75%) patients did not resume
radiation after interruption, despite counseling.
DISCUSSION
In the present study conducted on 1200 patients receiving
radiation over a 15‑month period, 100 (8.3%) patients
discontinued radiation treatment, which is lower than what
has been reported in most other studies in the literature.
The retrospective study on treatment interruption in patients
with cancer treated between 2012 and 2013 by Razmjoo et al.
showed that of a total of 1476 cases, there were 432 (29.3%)
treatment breaks.[1]
Giddings analyzed 471 patients with
head-and-neck cancer from 2006 to 2008 and found that
there were 74% treatment interruptions during radiation.[3]
Lee et al., in their study on treatment interruptions during
radiation therapy, found 220 (13.4%) radiation treatment
interruptions in a total of 1500 patients.[7]
Our low level of
treatment interruptions or dropouts may have been due to
the counseling system put in place at multiple levels as a
part of routine care.
In our study, the maximum number of dropouts (20%) were
due to treatment‑related toxicity, especially mucositis and
dysphagia. Acute radiation reaction, that is, a reaction
Total number of patients’ case sheets
accessed from the institutional medical
records from May 2009 to July 2010
(n = 1378)
Excluded (n = 178)
• Complete demographic data missing (n = 23)
• Complete treatment records missing (n = 155)
Final enrolled population
(n = 1200)
Type of radiation treatment received (n = 1200)
• Curative (n = 1142): 50–70 Gy radiotherapy +/- concurrent chemotherapy
• Palliative (n = 58): 30 Gy, only radiotherapy
Treatment completion (n = 1200)
• Completed full treatment course without interruption (n = 1100)
• Treatment interrupted >5 consecutive days excluding public holidays
(n = 100)
○ Treatment restarted after telephonic counseling (n = 25)
○ Treatment not completed despite telephone counseling (n = 75)
Analysis set (patients with treatment interruptions) (n = 100)
• Patients contacted over telephone (n = 100)
• Patients who provided reasons for interruptions (n = 100)
Figure1:Flowdiagramshowingtheselectionprocessofthestudypopulation
Table 2: Clinicodemographic details and the intent of treatment
of patients enrolled in the study on radiotherapy interruptions
Variable Number of patients (percentage) (n=1200)
Sex
Male 724 (60.4)
Female 476 (39.6)
Tumor site
Head-and-neck 379 (31.6)
Brain 52 (4.3)
Breast 128 (10.7)
Gynecological 301 (25.1)
Gastrointestinal 142 (11.8)
Genitourinary 83 (6.9)
Others* 115 (9.6)
Intent of therapy
Curative 1142 (95.2)
Palliative 58 (4.8)
*Soft tissue sarcoma (15 [1.25%]), Ewing’s sarcoma (15 [1.25%]), acute leukemia
(5 [0.4%]), lung (10 [0.8%]), lymphoma (30 [2.5%]), Wilms’ tumor (5 [0.4%]),
rhabdomyosarcoma (4 [0.3%]), and bone metastasis (31 [2.6%])
Table 3: Details of the patients enrolled in the study, who received radiation treatment, and the dropouts, that is patients who did
not receive radiation for five consecutive days, excluding weekends and public holidays
Event Number of patients (percentage) (n=1200)
Total number of patients started on radiation 1200 (100)
Patients who did not receive radiation for five consecutive treatment days (i.e., dropouts) 100 (8.3)
Reasons for dropouts (n=100)
Death
Social issues
Toxicity*
Progressive disease
Referral misguidance**
Incorrect satisfaction with early tumor response by patient or family
Financial issues
Non-compliance***
Change in treatment
Machine breakdown
15 (15% of total dropouts)
Number of patients who resumed treatment after counseling 25 (25% of total dropouts)
*Toxicities included mucositis (11 [55%] patients), dysphagia (9 [45%] patients), and vomiting (3 [15%] patients) **Sometimes patients who had been referred to non‑oncology
doctors for the management of comorbid conditions were misguided by them regarding treatment completion due to a lack of knowledge about the course and regimen of the
radiotherapy. ***Patients did not complete the scheduled treatment due to various reasons, for example, a family problem that necessitated the patient to return home (locally, far
away from the treatment center) midway through the treatment
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that occurs during radiation treatment and up to 6 weeks
after treatment completion, was the most common cause
of treatment interruption in the study on radiotherapy in
nasopharyngeal cancers by Chen et al.[8]
Acute radiation
reactions are inevitable and are the most common reasons
for non-compliance of patients. The management of these
toxicities would include early detection during weekly
reviews by the radiation oncologist and adequate use of
supportive medications.
Muzumder et al. in their study found that of 148 patients with
head-and-neck cancers treated with radiotherapy, 46 (31%)
had treatment interruptions, which was higher than what
we noted in our study (20%).[9]
The Grade 3 acute toxicities
in the study by Muzumder et al. included dysphagia (46.1%),
mucositis (28.5%), and nausea and vomiting (0%), while in
our study, the most common acute toxicity was Grade 3
mucositis (55%) followed by dysphagia (45%) and nausea and
vomiting (15%). Radiation mucositis leads to pain, dysphagia,
dependency on nasogastric tube feeding, weight loss, and
possibly even death due to aspiration. This depends on the
tumor site, volume of tissue irradiated, treatment dose,
and fractionation. Concurrent chemotherapy further adds
compounds mucositis. These effects can be mitigated by
the use of midline blocks or conformal radiation technique,
benzydamine mouthwash, nasogastric tube for feeding,
and nutritional supplementation during the entire course
of radiotherapy.[10‑13]
Acute gastrointestinal toxicity results
from radiation‑induced death of intestinal stem cells in the
intestinal crypts that are unable to replace the damaged
surface epithelium. Radiation also leads to damage to the
underlying blood vessels.[14]
Gastrointestinal toxicity can be
in the form of nausea, vomiting, loss of appetite, bleeding,
and diarrhea. It depends on many factors such as site of
the primary tumor, treatment volume, total dose, and
fractionation.[15]
Strategies for preventing gastrointestinal
toxicity include following full bladder protocol for treatment
as this will displace the small bowel out of the radiation
portals, treating in the prone position with a belly board that
will allow the bowel to fall off with gravity to outside the
radiation field, and using intensity‑modulated radiotherapy,
image‑guided radiotherapy, proton therapy, or brachytherapy
that will target the tumor while sparing the normal tissues.
Gastrointestinal toxicity can be well managed by nutritional
support and diet.[15‑18]
These acute toxicities can be mitigated
by proper counseling before the start and throughout the
radiation treatment regarding possible side-effects and
advising necessary medications during a regular review of
patients every week during the treatment. Additionally, the
patients need to be educated that these acute side-effects are
temporary and will resolve after the completion of treatment.
The second most common cause of treatment interruption in
our study was death, which accounted for 15% of dropouts.
A retrospective analysis of 56 patients was conducted by
Domschikowski et al., to find the cause of death in patients
treated with radiotherapy. The most common cause of death
was multi‑organ failure related to cancer (26 patients),
followed by combined causes of tumor and infection, cardiac
complications, and embolism (16 patients) and causes
unrelated to cancer (cardiac infarction, infection, respiratory
failure, etc.) (14 patients).[19]
Thus, the death of patients
during radiotherapy could be due to coexisting infection,
hematologic toxicities in patients receiving concurrent
chemotherapy, comorbid conditions, mismanaged toxicities,
nutrition problems, electrolyte imbalance, etc. Dropouts
due to death are cause‑specific and can be decreased by
performing a thorough complete initial evaluation and review
of all the comorbidities at regular reviews and timely referrals.
Patients with high‑risk comorbidities should strive to consult
with their non‑oncology physicians during radiation for the
management of their comorbidities.[20]
We found that 15% of the patients interrupted radiation
treatment due to financial issues. Radiation treatment is
costly and patients had to travel daily during the course of
treatment, which added to the financial burden on the family.
Many families were unable to bear such huge expenses unless
helped by non-governmental organizations or societies. Some
of the patients had to rent an apartment for 1–2 months near
the hospital to enable them to complete the treatment. . Some
patients and their relatives were unable to resume radiation
after interruption, due to ongoing financial problems.
Unfortunately, details regarding the income of the patients
were not available. Razmjoo et al. showed that 1.9% of the
patients had to interrupt their treatment due to monetary
problems.[1]
Health Minister’s Cancer Patient Fund helps in
providing financial assistance to patients with cancer below
the poverty line.[21]
Financial issues can be solved by taking
the help of various non-governmental organizations and trust
societies and referring needy patients to government hospitals
for treatment.[22,23]
The most common cause of treatment breaks in the study
by Lee et al. was tumor progression including death, which
was seen in 30% of patients.[7]
Dropouts due to progressive
disease accounted for 10% of the total dropouts in our study.
This is usually seen in cases with advanced disease, mostly
in patients with head-and-neck cancers. The cause of early
disease progression may have been due to aggressive tumor
biology or an incorrect plan of treatment starting from the
decision to administer radiation, drawing wrong contours,
or a bad radiation plan (any plan by the physicist that was
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not according to the standard or any plan in which further
modification could have resulted in better tumor coverage
and sparing of the normal tissues from radiation exposure,
thus leading to decreased toxicity). These issues need to
be addressed meticulously by ensuring that treatment is
delivered by a multidisciplinary team, following adequate
and appropriate radiation guidelines, and peer review of
radiation contours and plans.[24‑26]
In our study, treatment interruption due to social issues
occurred in 12% of patients. Dropouts due to social
issues were mainly because of old age (poor mobility and
lack of caregivers), social inhibition, lack of adequate
caregiver support, lack of knowledge about the disease,
fearfulness (particularly of the side-effects of radiation),
etc. Dropouts due to social issues can be solved by proper
counseling and increasing awareness about the disease and
the importance of completing the whole course of radiation
treatment to the patient’s outcome and survival.
Radiation treatment is usually delivered over six to eight
weeks depending on the tumor site, and the course is
protracted as compared to other treatments. Dropouts due
to referral misguidance are because doctors without oncology
training lack knowledge about the radiation treatment
duration. Therefore, when sending these patients to other
specialty doctors for the treatment of various comorbid
illnesses, management of toxicity, and other related issues,
they may be misguided and assume that the radiation is
complete, so they may not send the patients back to the
Radiation Oncology Department. Dropouts due to referral
misguidance occurred in around 9% of all dropouts in the
present study. This issue could be mitigated by providing
adequate information to non‑oncology doctors regarding
the radiation treatment schedules and the importance of
adherence to the prognosis and overall survival of patients.
Some patients whose tumors responded rapidly during
treatment, mostly as a result of regression of a large nodal mass
or symptomatic benefit, felt satisfied and wrongly concluded
that the disease was cured, and they therefore discontinued
treatment. In the current study, six (6%) patients interrupted
their treatment due to the false belief that the disease had
been prematurely cured. Such dropouts could be prevented by
proper counseling regarding the fact that cure of the disease
wouldbepossibleonlyoncompletionoftheplannedtreatment
and discussing the likelihood of recurrence of the disease and
incurability in case of incomplete therapy.
Decision change by the radiation oncologist during treatment
occurred in 6% of patients, which led to dropouts. This issue
may be prevented by peer review by radiation oncology
colleagues and tumor board discussion for all cases before
the start of treatment.
In the study by Razmjoo et al., the most common cause of
treatment interruptions in Iran was machine breakdown
or maintenance accounting for 29.5% of interruptions,
followed by side-effects of radiation seen in 16.7% , public
holidays in 8.1%, and death in 5.3% of patients.[1]
Radiation
interruptions due to machine breakdown varied from
country to country—44% in the UK, 45% in Spain, and 2% in
Vancouver.[1]
Dropouts due to machine breakdown occur due
to frustration among the patients who end up having to wait
the whole day for the commencement of treatment. There
were no radiation interruptions due to machine breakdown
in our study. This was possible by instituting an annual
maintenance contract for the machines. An engineer was
deployed for our machines so that machine‑related problems
could be resolved expediently, and patients did not have to
wait long for their treatment. Additionally, our physicists or
technologists were trained to handle small machine problems
on their own.
In our study, dropouts due to non-compliance were seen in
seven (7%) patients. In the overall cohort, 25 (25%) patients
agreedtocontinueradiationaftercounseling.Thiswaspossible
because of proper counseling not just before the start of
radiationbutalsoduringradiationtherapy.Itisvitallyimportant
to discuss the importance of compliance to the planned
radiotherapy regimen with the patient and family members.
Table 4 summarizes the various causes of radiation treatment
dropouts and the suggested methods to solve each issue.
A limitation of our study was the lack of generalizability of the
results as it was a single institutional study, and the sample
size was relatively small. Additional studies with large sample
sizes are necessary to corroborate these results. We only
included patients who received long‑course radiotherapy or
concurrent chemoradiotherapy in the standard fractionation
scheme; short‑course therapy was not included except for
patients who were treated with palliative intent.
CONCLUSION
Inoursetup,8.3%ofourpatientshavetreatmentinterruptions.
The three most common causes of such interruptions are
acute radiation toxicity, financial issues, and death. Proper
counseling at various levels of patient interaction by the
radiation oncologist, radiation counselor, and radiation
therapy technologists throughout the treatment period
can decrease the dropouts in radiation treatment. Apart
from counseling, various other measures such as financial
assistance, motivating patients to continue despite radiation
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reactions, educating non‑oncology physicians regarding the
need for treatment compliance, and resolving the machine
breakdowns will further decrease these dropouts.
Author contributions
Study conception and design: all authors; data collection
and analysis: MA, KK, KLR; statistical analysis and manuscript
preparation: KCP, AA; manuscript editing: PSB, VKRP, MM,
VM; review and critical revision of the manuscript, and
final approval of the version to be published: all authors;
accountability for all aspects of the work: all authors.
Data sharing statement
Individual de‑identified participant data will be made
available on reasonable request, from Dr. Kanhu Charan
Patro drkcpatro@gmail.com), starting from the date of
publication, until 10 years after publication. Requests beyond
this time frame will be considered on a case‑by‑case basis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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7. Lee JA, Lee NK,Yoon WS,Yang DS, Kim CY, Lee SR, et al. Treatment
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Table 4: Causes of radiation treatment interruptions and possible solutions to mitigate individual issues
Causes of treatment dropouts Methods to mitigate the problem
Acute radiation toxicity during radiation •
Conformal radiation technique
•
Midline block
•
Nasogastric tube feeding
•
Mouthwash using benzydamine
•
Nutritional and diet supplementation
Death during radiation •
Comprehensive evaluation of all health‑related comorbidities before the start of
radiation
•
Steps to be taken to address such issues, such as setting up standard operating
procedures for the management of comorbid conditions before the start of radiation
Tumor progression during radiation •
Taking the help of a multidisciplinary tumor board to plan appropriate treatment
strategy before the start of radiation
•
Peer review of radiation contours and plans before treatment approval and delivery
Social issues such as older persons without caregivers, social
inhibition (fears and myths in the minds of patients regarding
treatment‑related side-effects), lack of knowledge of the
disease and radiation treatment, non-compliance by relatives
•
Proper counseling
•
Increasing awareness regarding cancer and the need for compliance with treatment
Financial issues •
Social donation from non-governmental organizations and, trust societies
•
Timely referral to government radiation centers
Referral misguidance* •
Educating non‑oncology physicians regarding the importance of radiation treatment
schedules and adherence to treatment for patient’s outcome
Discontinuing radiation treatment midway due to false
satisfaction with good response after few fractions of
radiation
•
Communicating with the patient and relatives during the initial visit and before the
start of radiation regarding the deleterious effect of recurrence of disease that can
result from terminating treatment midway
Changing decision during treatment by the treating physician •
Peer review
•
Tumor board case discussion
Machine breakdown or maintenance •
Annual and regular maintenance during weekends and holidays
•
Having an engineer on‑site for easy handling of machine issues
•
Giving training to the radiation physicist and technologist to handle minor
machine-related problems
*On referral to non‑oncology doctors for the management of comorbid conditions, patients are sometimes misguided by them regarding treatment completion due to ignorance
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