Clinical Investigation
Predictors of Radiation Therapy Noncompliance in an Urban Academic Cancer Center

https://doi.org/10.1016/j.ijrobp.2014.09.030Get rights and content

Purpose

To quantify the frequency of patient noncompliance in an urban radiation oncology department and identify predictors of noncompliance.

Methods and Materials

We identified patients treated with external beam radiation therapy (RT) with curative intent in our department from 2007 to 2012 for 1 of 7 commonly treated malignancies. Patients who missed 2 or more scheduled RT appointments were deemed “noncompliant.” An institutional database was referenced to obtain clinical and demographic information for each patient, as well as a quantitative estimate of each patient's socioeconomic status. Logistic regression was used to identify factors associated with RT noncompliance.

Results

A total of 2184 patients met eligibility criteria. Of these, 442 (20.2%) were deemed “noncompliant.” On multivariate analysis, statistically significant predictors of noncompliance included diagnosis of head-and-neck, cervical, or uterine cancer, treatment during winter months, low socioeconomic status, and use of a long treatment course (all P<.05).

Conclusion

This is the first large effort examining patient noncompliance with daily RT. We have identified demographic, clinical, and treatment-related factors that can be used to identify patients at high risk for noncompliance. These findings may inform future strategies to improve adherence to prescribed therapy.

Introduction

Patient noncompliance has long been recognized as an impediment to the effectiveness of medical interventions (1). Within the field of oncology, issues relating to noncompliance with cancer screening procedures (2) and long-term drug therapy (3) have received the most attention to date. Factors that have been associated with adherence to physician recommendations include education level and socioeconomic status (SES) (4).

Patient compliance with daily radiation treatments is a unique issue. In most curative settings, radiation therapy (RT) is delivered 5 days each week over 3 to 8 weeks in an outpatient setting. Although few studies have specifically examined patient compliance with daily RT, prolongation of the total RT course has been linked with inferior clinical outcomes for a number of solid tumors 5, 6, 7. Treatment prolongation is thought to detract from the efficacy by allowing tumor cell repopulation during the treatment course. This theory is supported by randomized trials demonstrating improved outcomes with accelerated RT schedules 8, 9.

Our radiation oncology department, situated in a county where the poverty rate exceeds 30%, serves a diverse and largely underprivileged urban population. Despite our best efforts to maximize patient compliance with daily treatments, patients often miss their scheduled appointments. In this study we used electronic databases to quantify the rate of patient noncompliance in our department and identify factors predictive of poor adherence to prescribed RT courses.

Section snippets

Data collection and patient selection

We queried our department's electronic medical record (Varian Medical Systems, Palo Alto, CA) to identify all patients treated with external beam RT (EBRT) with curative intent at our institution in the years 2007-2012 and to tabulate the number of scheduled EBRT appointments that those patients missed (“no-shows”). That list was then cross-referenced with demographic and tumor registry data using Clinical Looking Glass (CLG), an interactive software application developed at our institution to

Patient characteristics

We identified 5370 patients who were treated with RT in our department from the years 2007 to 2012. A total of 2284 of these patients were treated with curative intent for head-and-neck, breast (including ductal carcinoma in situ), lung, rectal, prostate, cervical, or uterine carcinoma and completed their EBRT course. Of those patients, 2184 had demographic data available in CLG and constituted our study population.

Patient characteristics are summarized in Table 1. Mean age at the time of RT

Discussion

In this analysis we found that a significant proportion of our patients receiving EBRT with curative intent miss multiple scheduled RT sessions. We identified several independent risk factors for patient noncompliance, including particular cancer diagnoses, treatment during winter months, low SES, and the use of a long treatment course. For particularly high-risk patients, the rate of noncompliance exceeded 40%.

Patient noncompliance with daily RT sessions can have numerous deleterious effects.

Conclusion

Patient noncompliance with curative RT is a significant problem in our urban radiation oncology department. Demographic, clinical, and treatment-related factors are predictive of RT noncompliance and may inform future strategies to improve adherence to prescribed therapy.

Acknowledgments

The authors thank Marianne Cintron and Alex Lukaj for their tireless efforts managing the clinic.

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    This research was supported in part by the Paul Calabresi Career Development Award for Clinical Oncology (5K12CA132783-05).

    Conflict of interest: none.

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